CONTRIBUTORS  TO  VOL.  I. 

BARNEY,  J.  DELLINGER,  M.D. 

BARRINGER,  B.  S.,  M.D. 

BEER,  EDWIN,  M.D. 

BUERGER,  LEO,  M.A.,  M.D. 

CORBUS,  B.  C.,  M.D. 

DODD,  WALTER  J.,  M.D. 

FOWLER,  H.  A.,  M.D. 

KEYES,  EDWARD  L.,  JR.,  M.D. 

LEWIS,  BRANSFORD,  M.D.,  B.Sc.,  F.A.C.S. 

OSGOOD,  ALFRED  T.,  M.D. 

PILCHER,  PAUL  MONROE,  A.M.,  M.D. 

QUINBY,  WILLIAM  C.,  M.D. 

SANFORD,  HENRY  L.,  M.D. 

SMITH,  GEORGE  GILBERT,  M.D. 

STEVENS,  A.  RAYMOND,  M.D. 

WARREN,  GEORGE  W.,  M.D. 

WATSON,  FRANCIS  S.,  M.D. 

YOUNG,  HUGH   HAMPTON,  M.D. 


IN  ORIGINAL  CONTRIBUTIONS  BY 
AMERICAN  AUTHORS 


EDITED  BY 

HUGH  CABOT,  M.D.,  F.A.C.S. 

CHIEF  OF  THE  GENITO-URINARY  DEPARTMENT  OF  THE  MASSACHUSETTS  GENERAL  HOSPITAL; 

ASSISTANT  PROFESSOR  OF  GENITO-URINARY  SURGERY   IN  THE  HARVARD 

MEDICAL    SCHOOL,  BOSTON,  MASSACHUSETTS 


VOLUME    I 

GENERAL  CONSIDERATIONS  -  DISEASES  OF  PENIS  AND 
URETHRA -DISEASES  OF  SCROTUM  AND  TESTICLE- 
DISEASES  OF  PROSTATE  AND  SEMINAL  VESICLES 


ILLUSTRATED  WITH    368   ENGRAVINGS  AND  7   PLATES 


UJ .        o 

O  I)  (o't 

if;? 


COPYRIGHT 

LEA    &    FEBIGER 

1918 


DEDICATED 


TO   WHOSE   SKILL   AND   INTEGRITY   AS  A'  SURGEON 

AND   TO   WHOSE   WISDOM,    GENTLENESS   AND    FORCE    OF   CHARACTER 
I   DESIRE   TO   EXPRESS  MY  DEBT   OF   GRATITUDE 


CONTRIBUTORS. 


J.  BELLINGER  BARNEY,  M.D., 

Genitourinary  Surgeon  to  Out-Patients  in  the  Massachusetts  General  Hospital ; 
Consulting  Genito-urinary  Surgeon  to  the  United  States  Marine  Hospital, 
Chelsea,  Mass.;  Assistant  in  Genito-urinary  Surgery  at  the  Harvard  Medical 
School,  Boston,  Mass. 

B.  S.  BARRINGER,  M.D., 

Instructor  in  Urology  in  the  Cornell  University  Medical  School;  Assistant 
Urologist  in  the  Bellevue  Hospital;  Assistant  Surgeon  in  the  Memorial 
Hospital,  New  York. 

EDWIN  BEER,  M.D., 

Visiting  Surgeon  to  the  Mt.  Sinai  Hospital;  Assistant  Visiting  Surgeon  to  the 
Bellevue  Hospital,  New  York. 

LEO  BUERGER,  M.A.,  M.D., 

Instructor  in  Clinical  Surgery  in  the  Columbia  University;  Associate  Visiting 
Surgeon  and  Associate  in  Surgical  Pathology  in  the  Mt.  Sinai  Hospital, 
New  York. 

B.  C.  CORBUS,  M.D., 

Instructor  of  Genito-urinary  Surgery  in  the  Rush  Medical  College,  Chicago,  111. 

WALTER  J.  DODD,  M.D., 

Instructor  in  Roentgenology  in  the  Harvard  Medical  School;  Roentgenologist 
at  the  Massachusetts  General  Hospital,  Boston,  Mass. 

H.  A.  FOWLER,  M.D., 

Professor  of  Genito-urinary  Surgery  in  Howard  University  Medical  School; 
Genito-urinary  Surgeon  to  the  New  Emergency  and  Freedmen's  Hospitals, 
Washington,  D.  C. 

EDWARD  L.  KEYES,  JR.,  M.D., 

Professor  of  Urology  in  the  Cornell  University  Medical  School;  Urologist 
to  the  Bellevue  Hospital;  Surgeon  to  St.  Vincent's  Hospital,  New  York. 

BRANSFORD  LEWIS,  M.D.,  B.Sc.,  F.A.C.S., 

Professor  of  Genito-urinary  Surgery  in  the  Medical  Department  of  the  St. 
Louis  University;  Genito-urinary  Surgeon  to  St.  John's  Hospital;  Con- 
sulting Genito-urinary  Surgeon  to  the  Frisco  Railway  Hospital,  St.  Louis,  Mo. 

ALFRED  T.  OSGOOD,  M.D., 

Professor  of  Genito-urinary  Surgery  in  the  New  York  University  and  Bellevue 
Hospital  Medical  College;  Associate  Urologist  in  the  Bellevue  Hospital; 
Consulting  Genito-urinary  Surgeon  to  the  Presbyterian  Hospital,  New  York. 

PAUL  MONROE  PILCHER,  A.M.,  M.D., 

Consulting  Surgeon  to  the  Eastern  Long  Island  Hospital;  Surgeon  at  the 
Pilcher  Private  Hospital,  Brooklyn,  New  York. 

WILLIAM  C.  QUINBY,  M.D., 

Assistant  in  Surgery  in  the  Harvard  Medical  School;  Urologist  to  the  Peter 
Bent  Brigham  Hospital,  Boston,  Mass. 

(vii) 


3*2.  %  74- 


viii  «>\TRIBUTORS 

HENRY  L.  SANFORD,  M.D., 

Instructor  in  Surgery  in  the  Medical  Department  of  the  Western  Reserve 
University;  Assistant  Visiting  Surgeon  in  the  Department  of  Genito- 
urinary Surgery  in  the  Lakeside  Hospital;  Visiting  Surgeon  to  the  City 
Hospital  in  charge  of  Genito-urinary  Surgery,  Cleveland,  Ohio. 

GEORGE  GILBERT  SMITH,  M.D., 

\~istant  in  Genito-urinary  Surgery  in  the  Harvard  Graduate  School;  Genito- 
urinary Surgeon  to  Out-Patients  in  the  Massachusetts  General  Hospital, 
Boston,  Mass. 

A.  RAYMOND  STEVENS,  M.D., 

Instructor  in  Genito-urinary  Surgery  in  the  New  York  University;  Assistant 
Attending  Surgeon,  Urological  Service,  Bellevue  Hospital;  Chief  of  the 
Urological  Clinic  in  the  Presbyterian  Hospital,  New  York. 

GEORGE  W.  WARREN,  M.D., 

Urologist  at  the  Lutheran  Hospital  of  Manhattan;  Associate  Genito-urinary 
Surgeon  to  St.  Mark's  Hospital,  New  York. 

FRANCIS  S.  WATSON,  M.D., 

Late  Lecturer  in  Genito-urinary  Surgery  in  the  Harvard  Medical  School; 
Late  Surgeon-in-Chief  in  the  Boston  City  Hospital,  Boston,  Mass. 

HUGH  HAMPTON  YOUNG.  M.D., 

Clinical  Professor  of  Urology  in  the  Johns  Hopkins  University;  Director  of 
the  James  Buchanan  Brady  Urological  Institute;  Visiting  Urologist  to  the 
Johns  Hopkins  Hospital,  Baltimore,  Aid.;  President  of  the  Alaryland  State 
Lunacy  Commission. 


PREFACE. 


UROLOGY  as  a  specialty  is  still  young.  It  is  not  more  than  a  genera- 
tion since  there  have  been  in  America  men  of  eminence  who  devoted 
themselves  exclusively  to  this  subject. 

The  surgeons  who  contributed  to  the  great  System  of  Genito- 
urinary Surgery,  by  the  late  Prince  A.  Morrow,  M.D.,  were  none  of 
them,  properly  speaking,  specialists.  They  were  general  surgeons 
whose  interests  had  attracted  them  to  this  branch  of  surgery  but 
who  still  devoted  most  of  their  time  to  general  work. 

The  development  of  the  specialty  has  been  due  to  refinements  in 
diagnosis  and  particularly  to  the  introduction  and  development  of 
the  cystoscope,  which  though  it  was  introduced  by  our  foreign  col- 
leagues, has  been  brought  to  its  highest  development  in  this  country. 
It  is  today  quite  impossible  for  the  general  surgeon  to  master  thor- 
oughly the  details  of  urological  diagnosis,  and  though  he  may  be  expert 
in  the  refinements  of  operative  treatment,  he  of  necessity  fulfils  the 
function  of  the  therapeutist  rather  than  that  of  the  diagnostician. 

The  development  of  the  last  generation  has  added  much  to  the  dig- 
nity of  urology.  More  and  more  the  care  and  management  of  venereal 
disease  has  fallen  in  the  background.  Syphilis  with  its  many  develop- 
ments has  become  almost  a  specialty  in  itself  and  largely  separated 
from  urology.  It  is  for  this  reason  that  it  has  seemed  wise  to  abandon 
the  heretofore  common  joint  consideration  of  genito-urinary  diseases 
and  syphilis  and  consider  this  disease  only  insofar  as  it  effects  the 
genito-urinary  apparatus.  This  separation  I  believe  is  certain  to 
become  more  rather  than  less  marked.  The  relation  of  syphilis  to 
genito-urinary  diseases  is  purely  incidental.  Many  of  its  develop- 
ments belong  far  more  truly  to  the  realm  of  the  internist  and  the 
neurologist  and  its  importance  in  the  community  justifies  its  being 
allowed  to  develop  unhampered  by  its  purely  accidental  relationship. 

An  important  reason  for  the  production  of  this  book  at  this  time  is 
that  there  have  developed  in  the  last  generation  in  this  country  a 
large  group  of  urologists,  many  of  whom  are  authorities,  not  only 

(ix) 


X  PREFACE 

here  but  in  the  world,  on  their  particular  subjects,  and  there  can  be  no 
doubt  that  this  specialty  stands  today  in  America  at  least  on  a  par 
with  the  position  which  it  has  made  for  itself  abroad.  No  longer  must 
recourse  be  had  to  foreign  clinics  to  learn  the  refinements  of  diagnosis 
and  treatment,  and  it  is  owing  to  this  group  of  men  that  they  should 
find  adequate  expression  here. 

All  composite  works  have  an  inherent  weakness  in  that  they  lack 
the  smoothness  and  balance  of  works  produced  by  a  single  author. 
There  is  always  a  certain  lack  of  proportion;  there  is  always  obvious 
difference  of  opinion  where  two  men  approach  the  same  subject  from 
slightly  different  angles.  This,  while  perhaps  objectionable  in  a  book 
intended  solely  and  chiefly  for  the  use  of  students,  is  not  in  fact  objec- 
tionable for  the  use  of  the  profession  at  large.  Such  a  work  as  this  is 
in  fact  a  correlated  set  of  monographs  and  makes  up  in  vigor  what  it 
may  lack  in  detail.  I  am  not  tempted,  therefore,  to  make  any  apology 
for  a  certain  degree  of  disjointedness,  since  I  do  not  regard  it  as  a 
cogent  objection.  Our  intention  has  been  to  give  articulate  expression 
to  American  urology,  and  if  in  this  we  have  been  successful  the  object 
has  been  achieved. 

H.  C. 

BOSTON,  MASS. 


CONTENTS. 


SECTION  I. 

CHAPTER  I. 

HISTORICAL    SKETCH    OF    GENITO-URINARY    SURGERY     IN 

AMERICA 17 

BY  F.  S.  WATSON,  M.D. 

CHAPTER  II. 

THE  CYSTOSCOPE  AND   ITS  USE 58 

BY  LEO  BUERGER,  M.A.,  M.D. 

CHAPTER  III. 

METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  THE  URINARY  TRACT     107 
BY  BRANSFORD  LEWIS,  M.D. 

CHAPTER  IV. 

THE   ROENTGENOLOGY  OF  THE  URINARY  TRACT    ....     147 
BY  WALTER  J.  DODD,  M.D. 

CHAPTER  V. 

SYPHILIS  OF  THE   GENITO-URINARY  ORGANS 161 

BY  B.  C.  CORBUS,  M.D. 


SECTION  II. 

THE  PENIS  AND   URETHRA. 

CHAPTER  VI. 

ANATOMY,  ANOMALIES  AND   INJURIES  OF  THE  PENIS      .      .     193 
BY  H.  A.  FOWLER,  M.D. 

(xi) 


xii  CONTENTS 


CHAPTER  VII. 

DISEASES  OF  THE   PENIS 223 

BY  GEORGE  W.  WARREN,  M.D. 


CHAPTER  VIII. 

GENITAL  ULCERS 240 

BY  B.  C.  CORBUS,  M.D. 


CHAPTER  IX. 

INFECTIONS  OF  THE  URETHRA  AND  PROSTATE  OTHER  THAN 

TUBERCULOSIS  .      .' 286 

BY  B.  S.  BARRINGER,  M.D. 


CHAPTER  X. 

DISEASES  OF  THE   URETHRA   IN   THE   FEMALE 336 

BY  A.  T.  OSGOOD,  M.D. 

CHAPTER  XI. 

STRICTURE  OF  THE  URETHRA 384 

BY  EDWARD  L.  KEYES,  JR.,  M.D. 


SECTION  III. 

DISEASES  OF  THE  SCROTUM   AND  TESTICLE. 

CHAPTER  XII. 

ANATOMY    AND    PHYSIOLOGY,    MALFORMATIONS,    INJURIES 

AND  TORSION   OF  THE  TESTICLE 417 

BY  GEORGE  GILBERT  SMITH,  M.D. 

CHAPTER  XIII. 

DISEASES  OF  THE  SCROTUM 447 

BY  A.  RAYMOND  STEVENS,  M.D. 

CHAPTER  XIV. 

HYDROCELE,  HEMATOCELE  AND  VARICOCELE 461 

BY  HENRY  L.  SANFORD,  M.D. 


CONTENTS  xill 

CHAPTER  XV. 

INFECTIONS  OF  THE  TESTICLE 485 

BY  J.  BELLINGER  BARNEY,  M.D. 


CHAPTER  XVI. 

GENITAL  TUBERCULOSIS 498 

BY  J.  DELLINGER  BARNEY,  M.D. 


CHAPTER  XVII. 

TUMORS  OF  THE  TESTICLE 534 

BY  EDWIN  BEER,  M.D. 


SECTION  IV. 

THE   PROSTATE  AND  SEMINAL  VESICLES. 

CHAPTER  XVIII. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  PROSTATE  AND  SEMINAL 

VESICLES 541 

BY  WM.  C.  QUINSY,  M.D. 

CHAPTER  XIX. 

PROSTATIC   OBSTRUCTIONS 553 

BY  PAUL  MONROE  PILCHER,  A.M.,  M.D. 

CHAPTER  XX. 

CANCER  OF  THE  PROSTATE '657 

BY  HUGH  HAMPTON  YOUNG,  M.D. 

CHAPTER  XXI. 

SARCOMA  OF  THE  PROSTATE 720 

BY  HUGH  HAMPTON  YOUNG,  M.D, 

CHAPTER  XXII. 

CALCULUS   DISEASE  OF  THE   PROSTATE 723 

BY  HUGH  HAMPTON  YOUNG,  M.D. 


MODERN  UROLOGY. 


SECTION  I. 


CHAPTER  I. 

HISTORICAL  SKETCH  OF  GENITO-URIXARY  SURGERY 

IN  AMERICA. 

BY  F.  S.  WATSON,  M.D. 

IT  is  but  ten  years  since  genito-urinary  surgery,  or,  as  it  is  usually 
called  today,  "urology,"  has  become  an  established  specialty  of  the 
medical  profession  in  America.  Before  that  time  nearly  all  who  con- 
tributed to  the  advance  of  knowledge  of  this  branch  of  surgery  were 
general  surgeons. 

Previous  to  1890  there  were  but  three  or  four  clinics  in  the  country 
devoted  to  the  care  of  patients  having  maladies  of  the  genito-urinary 
tract. 

The  first  recognition  of  genito-urinary  surgery  in  the  title  of  a 
teacher  of  medicine  in  this  country  was  that  given  to  Dr.  Van  Buren, 
of  New  York,  who,  in  1877,  held  the  position  of  professor  of  the 
principles  of  surgery,  with  diseases  of  the  genito-urinary  system,  and 
clinical  surgery  in  the  Bellevue  Hospital  Medical  College  (Fig.  1). 

Prior  to  1877  there  was  but  one  treatise  in  America  dealing  with 
the  subjects  which  are  included  in  this  field.  This  was  the  work  of 
the  elder  Gross,11  of  Philadelphia,  the  first  edition  of  which  appeared 
in  1851  and  the  last  in  1876.  It  was  the  third  work  of  its  kind  in  the 
English  language  at  that  time,  the  other  two  being  those  of  the  dis- 
tinguished English  surgeons,  Brodie  and  Coulson. 

The  contrast  offered  by  the  status  of  genito-urinary  surgery  today 
with  that  which  has  been  indicated  above  may  be  seen  by  the  large 
number  of  medical  men  who  confine  their  attention  exclusively  to 
the  study  and  care  of  the  diseases  of  the  genito-urinary  system;  by 
the  recognition  of  the  importance  and  growth  of  this  special  branch 
by  medical  schools,  in  many  of  which  departments  with  professors 
at  their  heads,  have  been  created  for  the  teaching  of  it;  by  the 
organization  of  several  associations  for  the  purpose  of  discussing 
MU  j—2  (17) 


18      SKETCH  OF  GENITO-URINARY  SURGERY  IX  AMERICA 

subjects  included  in  urology  and  of  advancing  our  knowledge  of  them. 
Finally,  there  have  been  published  in  the  last  twenty-two  years 
eleven  exhaustive  treatises  upon  diseases  of  the  genito-urinary  system, 
besides  many  important  monographs  concerning  certain  parts  of  it 
as  compared  with  the  two  works  which  were  produced  in  the  course 
of  the  preceding  forty  years. 


FIG.  1. — Doctor  W.  H.  Van  Buren,  professor  of  the  principles  of  surgery,  with  dis- 
eases of  the  genito-urinary  system  and  clinical  surgery,  in  Bellevue  Hospital  Medical 
College,  New  York. 

The  data  set  forth  above  are  evidence  that  in  the  wonderful  progress 
which  has  characterized  the  growth  of  surgical  science  in  the  last 
half-century  this  branch  of  it  has  had  its  full  share  and  kept  pace 
with  it. 


THE  ORGANIZATION  OF  ASSOCIATIONS  OF  UROLOGISTS. 

The  first  association  of  American  urologists,  which  bore  the  name 
of  the  American  Association  of  Genito-urinary  Surgeons,  came  into 
being  at  the  home  of  Dr.  Edward  L.  Keyes,  of  New  York,  on  the 


THE  ORGANIZATION  OF  ASSOCIATIONS  OF   UROLOGISTS     19 

evening  of  October  16,   1886.     When  the  organization  of  the  new 
association  was  complete,  the  gentlemen  who  had  been  invited  to 
meet  there  elected  Dr.  Keyes  as  its  first  president. 
The  list  of  the  original  members  is  as  follows: 

John  H.  Brinton,  Philadelphia; 

John  P.  Bryson,  St.  Louis; 

Arthur  T.  Cabot,  Boston; 

George  Chismore,  San  Francisco; 

Algernon  Garnett,  Hot  Springs; 

Francis  B.  Greenough,  Boston; 

Gilbert  C.  Greenway,  Hot  Springs; 

Samuel  W.  Gross,  Philadelphia; 

Moses  Gunn,  Chicago; 

William  H.  Kingston,  Montreal; 

J.  Xevins  Hyde,  Chicago; 

Edward  L.  Keyes,  New  York; 

Claudius  Mastin,  Mobile; 

Christian  Fenger,  Chicago; 

Prince  A.  Morrow,  New  York ; 

Fessenden  N.  Otis,  New  York; 

Roswell  Park,  Buffalo; 

Frank  W.  Rockwell,  Brooklyn; 

Nicholas  Senn,  Chicago; 

Frederick  Sturgis,  New  York; 

Robert  W.  Taylor,  New  York; 

J.  William  White,  Philadelphia. 

This  association  was  one  of  a  number  which  were  the  component 
parts  of  a  larger  general  body,  to  which  the  name  Association  of 
American  Physicians  and  Surgeons  was  given,  which  was  formed 
at  about  the  same  time  and  meets  triennially  in  Washington  in 
congress. 

The  membership  of  this  special  branch  of  that  body  was  limited  to 
the  number  of  thirty  until  recently,  and  it  was  the  intention  of  its 
original  members  to  admit  into  it  only  those  who  should  have 
demonstrated  unusual  ability  by  their  work  and  who  were  of  high 
character. 

Within  the  next  fourteen  years  the  field  of  urology  had  been  so 
greatly  extended  that  a  far  larger  number  of  men  than  hitherto  had 
been  drawn  into  it  and  devoted  themselves  exclusively  to  the  study 
of  the  subjects  which  are  included  in  it. 

Owing  to  this  there  was  a  demand  for  the  formation  of  another  and 
larger  association,  and  in  1900  the  American  Urological  Association 
wras  organized,  and  has  been  an  active  and  useful  body  since  that 
time. 

In  1913  a  third  association  of  urologists  was  formed  as  one  branch 
of  the  American  Medical  Association. 

In  1907  a  few  distinguished  French  surgeons  took  steps  for  the 
organization  of  an  international  body  of  urologists,  and  in  1908  there 


20      SKETCH  OF  GEN J TO-URINARY  SURGERY  IX  AMERICA 

came  into  existence  1'Association  Internationale  d'Urologie.  The  most 
renowned  specialist  of  his  time,  Professor  Felix  Guyon,  was  its  first 
president.  The  officers  of  the  first  congress,  which  met  September 
30-October  3,  1908,  in  Paris,  were: 

President,  Professor  J.  Albarran.  Vice  Presidents:  Professor 
Karl  Posner,  of  Berlin;  Dr.  F.  S.  Watson,  of  Boston.  Secretaire- 
general,  Dr.  E.  Desnos,  of  Paris.  Tresorier-general,  Dr.  O.  Pasteau, 
of  Paris. 

A  committee  composed  of  Drs.  F.  S. "Watson,  of  Boston  (chairman), 
John  Vanderpoel,  of  New  York  (secretary  and  delegate),  and  Hugh 
II.  Young,  of  Baltimore,  manages  the  affairs  of  the  American  branch 
of  the  international  association. 

Full  recognition  of  the  share  that  American  surgeons  have  had  in 
contributing  to  the  progress  of  surgical  science  in  this  branch  of  the 
profession  was  given  by  the  members  of  other  countries  to  America's 
representatives  at  the  first  congress. 

Summary  of  the  More  Important  Steps  of  Progress  in  Genito-urinary 
Surgery  in  the  Last  Forty  Years. — It  would  seem  appropriate  to  intro- 
duce a  short  statement  of  steps  of  progress  at  this  point  in  the  chapter, 
and  therefore  those  which  have  occurred  during  the  last  forty  years 
or  so  are  briefly  summarized  below: 

1.  The  revolutionizing  of  the  method  of  treatment  of  vesical  calculus^ 
by  the  crushing  operation — Litholapaxy. 

2.  Practically  speaking,  all  the  knowledge  we  possess  with  regard 
to  the  nature  and  treatment  of  vesical  tumors. 

3.  The  radical  surgical  treatment  of  the  hypertrophied  prostate 
by  removal  of  the  gland. 

4.  The  introduction  of  the  cystoscope  and  the  great  extension  of 
knowledge  secured  by  its  use. 

5.  The  introduction  of  the  ureteral  catheter  and  the  opportunity 
supplied  by  it  to  study  the  functional   capability  of  each  kidney 
separately. 

6.  Numerous  and  valuable  tests  to  determine  the  functional  con- 
dition of  the  kidneys. 

7.  Radiography  and  the  knowledge  gained  by  it,  more  especially 
of  renal  and  ureteral  calculus,  of  certain  conditions  of  the  kidneys, 
of  the  renal  pelvis  and  the  ureter. 

8.  The  devising  and  employment  of  numerous  new  surgical  pro- 
cedures and  contrivances,  among  which  may  be  noted: 

The  operations  of  nephrolithotomy,  nephropexy,  operations  upon 
the  ureters,  partial  resection  of  the  bladder,  total  cystectomy,  the 
removal  of  vesical  diverticula,  the  operation  of  prostatectomy,  plastic 
operations  upon  the  penis,  urethra,  and  bladder,  the  discoveries  con- 
cerning the  normal  caliber  of  the  male  urethra,  the  operation  of 
litholapaxy,  etc. 

Each  and  all  of  these  have  resulted  in  great  saving  of  human  life 
and  sparing  of  human  suffering. 


BRIEF  SKETCHES  OF  SOME  OF  THE  MORE  NOTABLE  MEN 
IN  THE  FIELD  OF  UROLOGY. 

The  group  of  surgeons  in  whose  hands  rested  the  early  development 
of  Urology  in  America,  was  composed  of  men  of  unusually  high  char- 
acter and  distinction.  Among  them  were  some  whose  work  has 
secured  for  them  international  recognition  and  fame,  and  has  marked 
them  as  among  the  most  distinguished  medical  men  of  their  time. 

It  has  seemed  to  the  writer  that  greater  interest  would  be  lent  to 
this  chapter  if  there  should  be  included  in  it  something  of  personal 
reference  to  a  few  of  the  most  notable  members  among  the  contributors 
to  Urology  in  this  country,  and  he  feels  confident  that  in  making 
the  selection  of  them  he  will  be  in  accord  with  the  views  of  the  greater 
number  of  his  colleagues,  and  that  his  choice  will  meet  with  their 
approval.  The  following  six  surgeons  are  the  subjects  of  the  brief 
sketches  that  follow: 

SAMUEL  1).  GROSS,  Professor  of  Surgery  in  the  Jefferson  Medical 
College  of  Philadelphia. 

HENRY  J.  BIGELOW,  Professor  of  Surgery  in  the  Harvard  Medical 
School  of  Boston. 

EDWARD  L.  KEYES,  Professor  of  Genito-urinary  Surgery,  Syphil- 
ology  and  Dermatology  in  the  Bellevue  Hospital  Medical  College  of 
Xew  York. 

ARTHUR  T.  CABOT,  Lecturer  in  Genito-urinary  Surgery  in  the 
Harvard  Medical  School,  and  Fellow  of  the  Corporation  of  Harvard 
University,  Boston  and  Cambridge. 

JOHN  P.  BRYSON,  of  St.  Louis. 

SAMUEL  ALEXANDER,  Professor  of  Genito-urinary  Surgery  in  the 
Medical  School  of  Cornell  University  of  New  York. 

Dr.  Samuel  D.  Gross,  of  Philadelphia  (Fig.  2). — The  elder  Gross,  as  he 
was  usually  called,  was  one  of  the  most  distinguished  citizens  of  Penn- 
sylvania as  well  as  the  most  distinguished  surgeon  of  that  State  of  his 
or  other  times.  He  stood  forth  from  his  fellows  by  virtue  of  his  rare 
personal  attributes,  his  broad  sense  of  humanity  and  wrarm  heart,  and 
because  he  bore  the  stamp  of  a  master  and  leader  of  men. 

He  was  the  most  authoritative  writer  on  surgical  matters  in  America 
in  his  day,  the  most  masterly  teacher,  one  of  the  most  finished  operators, 
and  was  the  highest  type  of  medical  practitioner.  In  character  he 
was  absolutely  upright,  of  decided  though  just  temper,  and  a  man 
of  great  human  kindness. 

In  an  admirable  address  upon  Dr.  Gross,  delivered  some  years  ago 
by  another  distinguished  physician  of  Philadelphia,  Dr.  John  Chalmers 
Da  Costa,  many  interesting  details  concerning  the  elder  Gross  are 
recounted.  The  following  quotations  are  taken  from  this  address: 

"Dr.  Gross  was  the  most  illustrious  graduate  of  Jefferson  Medical 
College.  He  was  the  most  celebrated  man  who  ever  taught  there. 
He  was  the  leading  surgical  writer  of  his  day.  He  was  among  the 
most  notable  of  the  great  men  of  the  nineteenth  century  who  really 


22      SKETCH  OF  GENITO-URINARY  SURGERY  IN  AMERICA 

created  the  magnificent  science  of  modern  surgery,  and  many  of  his 
views  influence  us  still. 

"Dr.  Gross  was  tall,  well  made,  and  moved  with  a  dignified  gait. 
He  had  a  noble  head,  a  broad,  high  forehead,  and  snow-white  hair. 
He  was  the  embodiment  of  professional  and  professorial  dignity, 
the  beau  ideal  of  a  wise  and  learned  surgeon. 


FIG.  2. — Dr.  Samuel  D.  Gross,  professor  of  surgery  in  Jefferson  Medical  College, 

Philadelphia^ 

"As  a  teacher,  Dr.  Gross  was  magnificent.  .  .  .  He  was 
animated,  profoundly  interested  in  what  he  was  doing,  absolutely 
convincing. 

"  Now  and  then  he  liked  to  tell  an  anecdote  in  order  to  fix  a  point  in 
the  memory.  He  used  to  say :  'A  mere  statement  is  a  nail  driven  into 
a  board.  A  story  bends  the  point  of  the  nail  and  holds  it  fast  in  place.' 

"As  an  operator,  Gross  was  calm,  painstaking,  careful.  He  was 
rapid,  but  not  hurried,  and  always  proceeded  so  that  students  might 
see  and  understand  what  he  was  doing." 

Two  little  incidents  are  told  in  the  course  of  Dr.  Da  Costa's  address 
which  throw  a  side-light  upon  Dr.  Gross's  character,  and  are  worthy 
to  be  recorded  here: 


SKETCHES  OF  NOTABLE  MEN  IN  THE  FIELD  OF  UROLOGY    23 

"On  one  occasion  a  patient  was  brought  into  the  clinic  and  was 
found  to  require  a  small  operation  on  the  foot.  Gross  determined 
to  do  it  at  once.  He  directed  one  of  the  junior  assistants  to  wash 
the  foot.  The  young  man  declined  to  do  so,  saying  that  he  had  not 
come  there  to  do  such  work.  The  professor  called  for  soap  and  water 
and  scrubbing  brushes  and  did  it  himself.  He  dismissed  the  assistant 
from  his  place  and  told  the  class  that  there  was  nothing  dirty  in 
surgery." 

"On  another  occasion  he  walked  into  the  out-patient  department, 
where  a  junior  assistant  was  speaking  in  a  very  imperative  manner 
to  one  of  the  poor  patients.  Gross  said:  'Young  man,  you  speak 
as  one  having  authority,  but  the  basis  of  all  authority  here  must  be 
kindness.'  ' 

Dr.  Gross  left  an  excellent  record  of  lithotomy  operations  performed 
by  him.  It  consisted  in  69  operations  of  lateral  lithotomy  upon 
children,  with  but  2  deaths. 

He  was  a  general  surgeon,  and  not  in  any  sense  a  specialist.  Among 
his  other  writings,  however,  is  that  to  which  reference  has  already 
been  made,  which  treats  of  the  diseases  of  the  urinary  organs,  and 
which  was  for  many  years  the  standard  authority  upon  the  subjects 
of  which  it  treats. 

In  the  last  edition  of  this  work  the  elder  Gross11  had  the  assistance 
of  his  son,  another  surgeon  of  remarkable  attributes,  and  in  that  book 
we  find  references  to  some  of  the  subjects  which  we  are  wont  to  regard 
as  being  essentially  of  modern  origin — such,  for  example,  as  the 
removal  of  vesical  tumors  and  partial  prostatectomy. 

In  the  chapter  on  Yesical  Tumors  in  the  last  edition  the  methods 
for  their  removal  are  described  as  avulsion,  ligature  of  the  pedicle  and 
excision,  curetting,  and  cutting  off  with  snare,  these  being  done 
through  the  dilated  female  urethra  or  through  a  perineal  boutonniere 
in  the  male. 

In  the  chapter  in  which  the  surgical  treatment  of  the  hypertrophied 
prostate  is  spoken  of  the  following  passage  occurs  (p.  114):  "When 
the  obstruction  to  micturition  is  complete  and  the  capacity  of  the 
bladder  is  greatly  diminished,  so  that  resort  to  the  catheter  becomes 
necessary  every  hour  .  .  .  the  permanent  retention  of  a  tube  in 
the  bladder  above  the  pubes  may  be  advisable  to  avert  impending 
death.  .  .  .  When  the  obstacle  to  the  passage  of  urine  depends 
upon  enlargement  of  the  middle  lobe  and  the  patient  is  in  fair  general 
health,  I  can  see  no  objection  to  excising  it.  ...  I  should  certainly 
prefer  it,  in  such  an  event,  to  the  formation  of  an  artificial  fistule  above 
the  pubes.  In  executing  the  operation  the  incisions  would  have  to 
be  the  same  as  in  the  lateral  operation  of  lithotomy,  and  the  enlarged 
lobe  could  be  easily  cut  away  with  probe-pointed  bistoury  or  a  pair 
of  probe-pointed  stout  scissors." 

Dr.  Gross's  activity  continued  throughout  a  very  long,  most  valuable, 
and  distinguished  career.  He  held  the  chair  of  surgery  in  no  less 
than  four  medical  colleges  in  America  during  his  life.  He  wrote  some 


24      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

of  the  most  important  surgical  works  of  his  time.  He  exercised  a 
strong  and  most  beneficial  influence  upon  the  profession  of  this  country, 
and  was  an  example  of  all  that  is  of  the  best  and  highest  in  the  physician. 
Few  men  have  been  held  in  so  high  esteem  as  he.  Few  have  better 
deserved  to  be  thus  regarded. 

Dr.  Henry  J.  Bigelow,  of  Boston  (Fig.  3). — Of  the  men  who  added 
luster  to  this  special  field  of  surgery,  Dr.  Henry  J.  Bigelow,  was  in  the 
eyes  of  many  of  his  contemporaries  the  most  striking  figure  and  had 
the  most  dominant  personality. 


FIG.  3. — Dr.  Henry  J.  Bigelow,  professor  of  surgery,  Harvard  Medical  School,  Boston. 

His  career  was  one  of  almost  unexampled  brilliancy  and  success. 
He  made  the  most  important  single  contribution  to  genito-urinary 
surgery  that  has  been  made  in  this  field.  He  was  vitally  instrumental 
in  causing  the  adoption  by  the  profession  of  the  greatest  boon  that 
has  perhaps  been  given  to  man — anesthesia  by  the  inhalation  of 
sulphuric  ether — which  was  first  administered  in  public  by  Dr.  Morton, 
of  Boston,  in  1846,  in  the  amphitheater  of  the  Massachusetts  General 
Hospital  to  a  patient  of  the  elder  Warren  (Fig.  4). 

Dr.  Bigelow  was  at  that  time  a  young  man,  just  beginning  his 
professional  career.  His  promotion  in  the  ranks  of  medical  men  was 


extraordinarily  rapid.  Two  years  after  he  had  begun  his  practice 
he  was  appointed  visiting  surgeon  to  the  Massachusetts  General 
Hospital,  and  three  years  later  was  given  the  position  of  professor 
of  surgery  in  the  Medical  School  of  Harvard  University. 

Much  of  his  medical  education  was  received  in  France,  and  he 
possessed,  whether  by  nature  or  by  his  early  association  with  the 
French  people,  a  large  share  of  their  finesse  and  mental  acumen. 

His  first  contributions  to  surgical  literature  were  published  when 
he  had  been  but  two  years  in  practice,  and  whatever  he  made  public 
thereafter  was  of  high  quality  and  value. 

Dr.  Bigelow  was  tall,  handsome,  graceful,  of  polished  manners, 
a  thorough  man  of  the  \vorld,  and  a  patrician. 


FIG.  4. — The  first  administration  of  ether  in  the  old  amphitheater  of  the  Massa- 
chusetts General  Hospital,  1846. 

If  one  recalls  the  gatherings  of  medical  men  of  one  or  another 
of  the  international  medical  congresses,  those  who  are  most  clearly 
stamped  on  the  memory,  among  their  members,  are:  Pasteur,  Lister, 
Virchow,  von  Langenbeck,  Bigelow,  Sir  William  Macewen,  Sir  William 
MacCormac,  and  Sir  James  Paget.  All  of  them  truly  remarkable, 
most  of  them  great  men.  Bigelow  was  not  the  least  among  them. 

Bigelow's  mental  qualities  were  such  as  to  place  him  in  the  class  of 
men  we  call  geniuses.  The  chief  characteristic  of  his  mind  was  that  of 
seizing  with  extraordinary  rapidity  and  in  unerring  fashion  upon  the 
vital  point  of  the  problem  presented  to  him  and  of  remaining  absorbed 
in  it  until  he  had  established  it  to  his  satisfaction  in  all  its  bearings. 
One  might  liken  the  working  of  his  mind  to  the  swift  plunge  of  a 
fish  hawrk  when  it  drops  into  the  water  and  fixes  its  talons  in  the 
submerged  prey. 

As  an  operator  his  coordination  of  mind  and  hand  were  more  perfect, 


26      SKETCH  OF  GENITO-URIXARY  SURGERY  IN  AMERICA 

the  delicacy,  deftness,  and  precision  of  movement  more  remarkable 
than  it  has  ever  been  the  fortune  of  the  writer  to  see  exhibited  by  any 
other  surgeon.  He  added  grace  and  finish  to  all  his  work.  His  hands 
never  made  groping  motions,  but  went  direct  to  and  from  the  objects 
they  sought  with  swift,  single  movements.  His  sense  of  touch  was 
so  keen  that  it  often  gave  him  the  power  to  make  almost  instantaneous 
and  correct  diagnoses  which  other  men  failed  of  doing. 

As  a  teacher  he  was  equally  remarkable.  The  value  of  his  lectures 
was  enhanced  by  his  power  of  graphic,  often  dramatic  and  epigram- 
matic expression,  and  by  a  tendency,  which  may  have  been  in  part 
unconsciously  exercised,  in  part  done  with  intent,  to  stage  in  the 
most  telling  manner — if  one  can  apply  such  a  phrase  to  the  surgical 
amphitheater  of  a  hospital — the  scene  of  his  operations  and  teaching. 

One  little  example  of  his  way  of  summing  up  a  part  of  a  subject 
may  be  given  as  an  illustration  of  the  indelible  impression  which 
he  so  often  made  upon  his  students.  In  a  lecture  upon  dislocations 
of  the  joints  of  the  arm  he  concluded  his  remarks  thus :  "  A  great  many 
pages  have  been  written  and  many  illustrations  have  been  made  to 
describe  and  to  represent  numerous  complicated  bandages,  apparatuses, 
or  whatever,  employed  for  the  purpose  of  retaining  the  arm  in  its 
proper  position  after  reduction  of  a  dislocation  of  the  shoulder-joint 
has  been  effected.  The  whole  thing  consists  in  this:  pad  in  the  axilla, 
elbow  to  the  side,  arm  in  a  sling.  Good  morning,  gentlemen." 

He  would  have  been  as  successful  in  diplomacy,  or  in  a  number  of 
other  walks  of  life,  had  he  followed  any  one  of  them,  as  he  was  in  his 
chosen  profession. 

He  was  many-sided  and  his  mind  reached  out  in  many  directions. 
As  a  consequence  he  became  interested  from  time  to  time  in  a  number 
of  subjects  other  than  those  included  in  his  professional  work.  Among 
these  outside  excursions — if  one  may  so  call  them — may  be  mentioned : 
fancy  breeds  of  pigeons,  gems,  the  restoration  of  pictures,  soil  ferti- 
lizers, the  facial  expression  of  the  monkey. " 

Another  anecdote  of  Dr.  Bigelow  may  be  appropriately  told  here. 
He  was  walking  through  the  Boston  Art  Museum  with  the  curator 
of  the  institution.  As  they  passed  a  small  repository  in  which  some 
of  the  valuables  of  the  museum  were  placed  for  safe  keeping,  the 
doctor's  eye  fell  upon  its  lock.  He  stopped,  and  after  contemplating 
it  for  a  moment,  turned  to  the  curator  and  told  him  that  he  did  not 
think  the  lock  was  safe.  The  curator  did  not  agree  with  him.  "  Very 
well,"  said  Bigelow,  "I'll  bet  you  that  I  can  come  down  here  in  the 
course  of  the  next  few  days  and  pick  that  lock  in  ten  minutes."  The 
wager  was  taken.  A  day  or  two  later  a  visitor  calling  upon  the  doctor 
discovered  him  seated  at  his  desk  with  a  basket  filled  with  all  manner 
of  locks  beside  him,  while  locks  of  various  patterns  were  scattered 
freely  about  the  room.  "What  on  earth  are  you  doing?"  asked  the 
visitor.  "Oh,"  replied  the  Doctor,  "I  am  merely  getting  ready  to 
pick  one  of  the  locks  at  the  Art  Museum." 

In  the  course  of  the  next  four  days  he  came  to  the  museum  and 


SKETCHES  OF  NOTABLE  MEN  IN  THE  FIELD  OF  UROLOGY    27 

picked  the  lock  in  two  minutes  in  the  presence  of  the  curator.  The 
incident  illustrates  one  of  the  doctor's  mental  qualities  which  was 
that  of  becoming  absolutely  absorbed  in  the  study  of  a  problem  until 
he  had  reached  the  solution  of  it.  After  having  done  so  he  would 
frequently  cast  the  whole  matter  aside  as  though  it  had  never  interested 
him  at  all.  Sometimes  he  turned  over  the  finishing  of  the  detail  of 
his  problem  to  another,  after  he  had  solved  the  chief  point  of  interest 
in  it;  yet  no  one  ever  carried  detail  to  more  complete  and  finished 
consummation  than  he,  if  he  desired  to  do  so. 

He  was  the  author  of  the  most  important  single  contribution  that 
has  been  made  to  the  field  of  genito-urinary  surgery.  This  was  his 
operation  known  as  litholapaxy,  of  which  more  extended  description 
will  be  given  farther  on  in  this  chapter. 

On  entering  the  surgical  amphitheater  Bigelow  would  sometimes 
find  a  colleague  who  had  encountered  a  check  in  the  course  of  the 
performance  of  an  operation,  such,  for  example,  as  that  which  is 
offered  at  times  by  the  difficulty  of  finding  the  posterior  end  of  a 
ruptured  or  tightly  strictured  urethra.  Bigelow  would  watch  his 
colleague's  efforts,  for  a  moment,  then  say  to  him,  "Want  to  let  me 
have  a  try  at  that?"  Assent  being  given,  he  would  take  the  instru- 
ment in  his  hand,  and,  presto!  the  thing  was  done  in  one  movement. 

Nature  had  gifted  him  with  rare  attributes;  he  developed  many 
of  them  to  a  high  degree  of  perfection.  Possessed  of  a  mind  that  was 
constant  in  its  inquiry  into  the  nature  of  various  phenomena,  gifted 
with  clear  vision  and  accurate  powers  of  observation,  these  qualities 
being  enhanced  by  a  striking  power  of  expression,  by  an  impressive 
bearing  and  dominating  personality,  he  stands  out  in  one's  memory 
as  the  most  remarkable  figure  in  the  profession  of  medicine  in  this 
country  in  his  day. 

Edward  L.  Keyes,  of  New  York  (Fig.  5). — One  of  the  admirers  and 
followers  of  the  teachings  of  Dr.  Keyes  placed  in  a  treatise  which  he 
published,  many  years  after  first  meeting  him,  the  following  inscription 
as  a  dedication  to  the  volume:  To  Edward  L.  Keyes — surgeon, 
author,  teacher,  and  master  in  his  field  of  the  profession — the  author 
dedicates  this  work  as  a  token  of  his  respect  and  esteem. 

Far  too  brief  a  summary  to  address  to  one  of  the  foremost  masters 
of  his  day  in  the- medical  profession  in  America. 

Dr.  Keyes  won  a  conspicuous  place  in  surgery,  and  especially  in 
urology,  at  a  very  early  period  of  his  career.  He  first  became  known 
to  the  medical  public  as  the  junior  author  of  a  work  on  Genito-urinary 
Diseases  and  Syphilis,  the  senior  author  of  which  was  Dr.  Van  Buren, 
of  New  York.  This  work  and  its  succeeding  edition,  the  later  ones  of 
which  have  been  the  work  of  the  younger  Keyes,  has  held  its  place 
as  the  most  popular  text-book  in  this  field  of  surgery  from  1874  to 
the  present  time. 

The  chapters  on  Calculus  in  the  first  edition  were  the  work  of 
Dr.  Van  Buren,  the  rest  of  the  volume  being  entirely  written  by 
Keyes.  In  a  private  letter  to  the  writer,  Dr.  Keyes  says  that  Dr. 


28      SKETCH  OF  GEN  1  TO-URINARY  SURGERY  IN  AMERICA 

Van  Buren  revised  the  whole  work,  and  speaks  in  terms  of  highest 
praise  and  with  warm  gratitude  of  his  own  indebtedness  to  his  senior 
associate  who  was  a  widely  known  surgeon  in  New  York. 

Dr.  Keyes  had  scarcely  started  in  the  practice  of  his  profession 
when  he  undertook  this  work,  and  it  is  a  great  tribute  to  his  powers. 
The  work  is  remarkable  for  its  direct,  terse,  lucid  style  and  for  the 
practical  manner  in  which  the  subjects  are  treated,  thus  giving  to  it 
an  especial  value  to  the  students  of  medicine. 


FIG.  5. — Dr.  Edward  L.  Keyes,  professor  of  genito-urinary  surgery,  syphilography,  and 
dermatology  in  the  Bellevue  Hospital  Medical  College,  New  York. 

For  more  than  twenty-five  years  Dr.  Keyes  was  the  highest  authority 
in  what  we  call  an  "all-round"  sense,  in  this  country,  in  the  field  of 
urology.  He  was  not,  however,  a  specialist,  but  a  general  surgeon. 

Dr.  Keyes  was  a  teacher  of  rare  power,  and  the  writer  well  remembers 
the  strong  impression  made  upon  him  by  his  teaching  when  he  had  the 
good  fortune  to  hear  his  lectures  during  a  winter  passed  in  New  York 
many  years  ago.  He  presented  his  subject  in  a  terse,  forceful,  and 
practical  manner,  and  caught  and  absolutely  held  the  attention  of 
his  students  as  few  teachers  are  able  to  do. 

He  was  masterful,  a  natural  leader  of  men,  filled  with  a  super- 


SKETCHES  OF  XOTABLE  ME\  IX  THE  FIELD  OF 


abundant  energy,  capable  of  doing  an  enormous  amount  of  work 
day  in  and  day  out. 

One  recognized  in  Dr.  Keyes  at  first  glance  the  integrity,  directness, 
and  honesty  of  the  man,  and  saw  a  look  of  determination  that  was 
an  index  of  character  that  must  have  meant  much  in  the  building  of 
-  iccessful  career. 

His  influence  and  his  work  have  been  of  great  value  to  surgical 
science  and  to  his  col  nd  have  won  for  him  universal  respect 

and  esteem  most  well  deserved. 


FIG.  6. — Dr.  Arthur  T.  Cabot,  instructor  in  penito-urinary  sureery.  Harvard  Medical 
Sehool,  Fellow  of  the  Corporation  of  Harvard  University,  Boston. 

Dr.  Arthur  T.  Cabot,  of  Boston  (Y\g.  (>>.  and  Dr.  John  P.  Bryson,  of  St. 
Louis.-  One  instinctively  associates  these  t\vo  men  in  one's  memory 
because  of  their  having  possessed  certain  sterling  and  high  qualities 
in  common  and  because  of  the  nobility  and  manliness  of  their  char- 
acters. No  one  possessing  mean,  dishonest,  or  underhand  traits  of 
human  nature,  it  may  be  believed,  ever  came  into  the  presence  of 
either  without  being  conscious  of  a  rebuke  to  those  qualities.  Both 
stood  for  what  they  believed  to  be  right,  and  were  uncompromising 
in  advocating  it  and  in  condemning  what  they  believed  to  be  wrong. 


30      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

The  value  of  their  service  was  greater  by  virtue  of  their  character 
as  men  rather  than  for  the  originality  of  the  work  which  they  con- 
tributed to  this  field  of  the  profession.  Few,  if  any,  medical  men 
exercised  a  stronger  influence  for  good  in  their  profession  than  these 
two.  With  Dr.  Cabot  its  effect  reached  far  beyond  his  profession, 
indeed,  for  he  rendered  distinguished  service  in  other  fields  of  public 
work  as  well.  His  most  notable  services  of  this  kind  were  those 
rendered  by  him  in  his  positions  as  a  member  of  the  corporation  of 
Harvard  University,  as  trustee  of  the  Boston  Art  Museum,  and  as 
chairman  of  the  board  that  was  organized  to  limit  the  spread  of 
tuberculosis  in  the  United  States. 

In  these  offices  as  well  as  in  those  of  teacher  in  the  medical  school 
of  Harvard  University  for  several  years,  as  visiting  surgeon  to  the 
Massachusetts  General  Hospital,  and  as  one  of  the  best  practitioners 
of  medicine  in  his  town,  he  rendered  great  public  service,  and  the 
value  of  all  of  it  was  enhanced  by  the  fact  of  his  being  a  thorough 
gentleman  and  high-minded  man. 

The  first  recognition  of  urology  as  a  special  department  of  the 
medical  profession  given  by  Harvard  University  was  in  its  appoint- 
ment of  Dr.  Cabot  as  an  instructor  in  genito-urinary  surgery  in  the 
Medical  School  of  Harvard  in  the  year  1880. 

As  an  operator,  Dr.  Cabot  was  careful,  deliberate,  calm,  thorough; 
as  a  surgeon,  he  was  wise  and  conscientious;  as  a  man,  humane, 
upright,  straightforward  and  honorable.  His  temper  was  sharp 
but  just. 

Apart  from  his  profession  and  the  public  works  already  mentioned, 
he  displayed  unusual  capabilities  in  his  diversions,  for  he  was  as  an 
amateur  an  uncommonly  good  painter  of  pictures  in  water  color,  and 
a  very  keen  and  admirable  sportsman.  He  was  one  of  the  best  shots 
in  the  community.  He  was  fond  of  the  country  and  of  animals,  a 
good  cross-country  rider,  and  a  polo  player.  These  were  his  principal 
diversions,  and  he  enjoyed  them  and  exhibited  in  them  a  capability 
of  character  similar  to  that  displayed  in  his  professional  work. 

John  P.  Bryson,  of  St.  Louis. — An  exponent  of  manliness  and  honesty! 
These  are  the  qualities  of  which  one  first  thinks  when  recalling  Dr. 
Bryson  and  his  work.  The  first  of  them  was  put  to  the  test,  and 
doubtless  fortified,  when,  at  the  age  of  seventeen,  as  a  private  soldier 
in  the  army  of  the  South,  during  the  Civil  War  in  America,  he  was 
in  the  thickest  of  the  fighting  in  the  two  days'  battle  at  Gettysburg. 
It  was  a  rough  initiation  to  life  that  he  received  on  that  field,  but  it 
stood  him  in  good  stead  throughout  a  most  useful  and  valuable  life, 
in  which  all  his  efforts  were  directed  to  relieving  human  suffering. 

Reliable,  strong,  and  honorable — always  dealing  telling  blows 
for  good  causes,  and  always  ranging  himself  against  all  that  was  less 
worthy  in  human  nature,  warm  of  heart  and  of  tender  humanity. 
He,  too,  exercised  a  strong  and  beneficent  influence  in  his  profession. 
Dr.  Bryson  was  a  general  surgeon,  though  in  the  later  years  of  his  life 
he  was  identified  chiefly  with  the  field  of  genito-urinary  surgery,  and 


SKETCHES  OF  NOTABLE  MEN  IN  THE  FIELD  OF  UROLOGY     31 

for  a  number  of  years  contributed  to  it  work  of   high,  though  not 
strikingly  original,  character. 

Dr.  Samuel  Alexander,  of  New  York  (Fig.  7).— A  man  possessed 
essentially  of  the  temperament  and  nature  of  a  genius,  one  who  unaided 
by  the  physical  traits  that  often  play  so  important  a  part  in  the  effect 
produced  by  certain  men,  none  the  less  dominated  in  remarkable  degree 
those  who  came  in  contact  with  him.  His  nature,  his  manner  and  speech 
may  be  designated  without  exaggeration  as  fervid.  His  enthusiasm 
for  his  work,  for  his  teaching,  in  his  researches,  was  hot  and  seemingly 


FIG.  7. — Dr.  Samuel  Alexander. 

inexhaustible;  moreover  it  was  contagious,  and  owing  to  this  he  was 
a  teacher  who,  so  to  speak,  gripped  his  students  by  the  throat.  He 
held  them  in  closest  attention  and  inspired  them  with  his  own  en- 
thusiasm more  perhaps  than  any  other  teacher  of  his  day.  As  a  lecturer 
he  was  rapid  of  speech,  vitalized  to  the  finger-tips,  lost  in  his  subject, 
oblivious  of  self;  intent  only  on  lodging  the  information  which  he 
desired  to  impart  in  the  minds  of  his  listeners,  and  succeeding  in  so 
doing  as  it  is  given  to  but  few  men  to  succeed. 

Dr.  Alexander  was  not  a  general  surgeon,  and  is  the  only  one  of 


32       SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

those  of  whom  these  short  sketches  have  been  written  who  was 
definitely  a  specialist,  for  he  confined  his  work  entirely  to  genito- 
urinary surgery  and  syphilis.  His  mind  was  of  a  distinctly  original 
quality,  although  the  actual  original  work  that  he  produced  was  not 
so  much  in  amount  as  he  doubtless  would  have  contributed  but  for 
his  early  death,  and  being  hampered  for  several  years  by  serious 
illness.  His  contributions  to  genito-urinary  surgery  were,  however, 
all  of  them,  of  distinctive  character,  and  all  of  them  marked  by  original 
expression  and  thought.  They  were  always  thorough,  carefully  pre- 
pared, beautifully  illustrated,  and  presented  without  thought  of  any 
personal  advantage  that  might  be  derived  from  them.  He  was  more 
notable  as  a  teacher  than  as  an  operator,  though  he  did  not  lack  skill 
in  that  capacity. 

It  was  doubtless  true  of  the  other  members  of  the  association,  to 
which  the  writer  and  Alexander  both  belonged,  that  they  looked 
forward,  as  he  did,  to  meeting  Alexander  at  each  of  its  annual  gatherings 
with  greater  pleasure  than  was  anticipated  from  any  other  feature  of 
them.  He  was  an  excellent  fighter,  hit  hard  and  straight,  never 
skirmished  for  a  technical  advantage  in  a  discussion,  but  fought 
vigorously  to  establish  his  views,  always  in  the  open.  It  was 
delightful  to  become  involved  in  a  good  hot  discussion  with  Sam; 
Alexander. 

The  following  sketch  of  Dr.  Francis  S.  Watson  is  written  by  Dr. 
Edward  L.  Keyes,  Jr.,  of  New  York,  at  the  request  of  the  editor  of 
this  work,  who  desires  to  include  its  subject  in  this  chapter: 

"Among  the  circle  of  men  who  have  maintained  the  high  standard 
of  urology  in  Boston  during  the  past  forty  years,  Dr.  Francis  S. 
Watson  is  unique  (Fig.  8). 

"  As  a  pupil  of  Bigelow,  he  inherited  the  best  traditions.  As  surgeon 
of  the  Boston  City  Hospital,  he  cultivated  his  inheritance.  As  the 
author  of  many  monographs  upon  urological  topics,  he  evinces  his 
lucidity  of  thought  and  keenness  of  observation.  But  in  his  case, 
as  in  that  of  all  memorable  men,  the  peculiar  force  of  his  personality 
is  what  stands  foremost  in  the  memory  of  those  who  know  him.  To 
say  that  his  wit  is  as  lucid  as  his  intelligence,  or  that  his  tireless  energy 
drives  both  to  incessant  display,  suggests  only  the  most  salient  of  his 
characteristics,  mellowed  as  these  are  by  a  great  gentleness  and 
intense  feeling  for  art  and  music,  and  above  all  a  whole-hearted  and 
generous  love  and  loyalty  for  his  fellows. 

"As  an  informal  teacher  (for  we  can  speak  with  no  knowledge 
of  his  work  with  the  undergraduates)  at  medical  societies  and  elsewhere 
such  a  personality  scintillates  with  suggestions;  even  more  perhaps 
in  its  obiter  dicta  than  in  the  direct  topic.  This  casual  brilliancy  is 
permanently  illustrated  in  that  work  which  he  would  be  the  last  to 
wish  placed  at  the  head  of  his  achievements,  a  three-act  travesty  on 
medical  foibles  and  New  England  rusticity,  entitled  'A  Day  with 
the  Specialists.' 

"  But  to  turn  from  the  gay  to  the  grave,  his  important  contributions 
to  medical  literature  are  numerous. 


SKETCHES  OF  NOTABLE  MEN  IN  THE  FIELD  OF  UROLOGY     33 

"In  1888  he  published  a  volume  entitled  Operative  Treatment  of 
the  Hypertrophied  Prostate,  which  both  by  its  textual  and  its  pictorial 
illustrations  of  pathological  conditions  has  been  the  foundation  for 
much  subsequent  work. 

"He  performed  his  first  perineal  prostatectomy  in  the  following 
year.  This  was  apparently  the  first  time  that  the  operation  was 
performed  in  America. 


FIG.  8. — Dr.  Francis  S.  Watson,  lecturer  on  genito-urinary  surgery,  Harvard  Medical 

School,  Boston. 

"Among  his  more  recent  contributions  we  may  mention  his  original 
method  of  nephropexy,  described  in  the  Boston  Medical  and  Surgical 
Journal,  July,  1896. 

"An  exhaustive  study  of  Subparietal  Injuries  of  the  Kidney,  Boston 
Medical  and  Surgical  Journal,  July  9  et  seq.,  1903. 

"Operative  Treatment  of  the  Hypertrophied  Prostate  (Annals 
of  Surgery,  June,  1904)  and  his  contributions  to  the  subject  of  vesical 
tumors,  Annals  of  Surgery,  1905  and  1907,  reviewing  the  disastrous 
surgical  history  of  this  condition,  and  urging  bilateral  preliminary 
nephrostomy  followed  by  total  cystectomy  for  certain  cases  of  malig- 
nant neoplasms. 

"In  1909  he  urged  unilateral  nephrolithotomy  in  the  treatment  of 

M  tJ      I — 3 


34       SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IX  AMERICA 

certain  cases  of  calculous  anuria  before  the  International  Urological 
Congress,  of  which  he  has  been  vice-president  since  the  inception  of  the 
International  Association  of  Urology,  and  the  bilateral  operation  in  a 
small  class  of  other  cases  of  the  same  condition. 

"The  summing  up  of  Dr.  Watson's  literary  contributions  and  surgical 
experience  is  a  two-volume  work  on  genito-urinary  surgery,  written 
with  the  assistance  of  Dr.  John  H.  Cunningham,  Jr.,  and  published 
by  Lea  &  Febiger  in  1908.  This  will  long  stand  as  a  monument  to 
the  genius  of  its  author." 

THE  EVOLUTION  OF  UROLOGY  IN  AMERICA. 

The  year  1851  is  selected  as  that  in  which  the  specialty  of  genito- 
urinary surgery  had  its  birth  in  this  country,  because  it  was  in  that 
year  that  the  elder  Gross  published  his  work  dealing  with  the  maladies 
of  the  urinary  organs.  This  was  the  first  work  of  this  character  in 
America,  and  the  third  one  in  the  English  language,  the  other  two 
being  the  treatises  of  the  noted  English  surgeons,  Brodie  and  Coulson. 

From  1851  until  1877  the  treatise  of  Gross  was  the  only  one  available 
to  students  of  this  special  branch  of  surgery  in  this  country.  It  had 
great  literary  value  and,  so  far  as  it  went,  was  a  full  and  thorough 
exposition  of  the  subjects  of  which  it  treated.  It  held  its  place  in 
medical  literature  and  in  the  world  of  medical  students  until  the 
year  1876,  when  its  last  edition  appeared. 

In  1877  the  first  edition  of  its  rival  and  successor,  the  work  of 
Van  Buren  and  Keyes,  already  referred  to,  was  published,  and  before 
long  superseded  its  predecessor. 

Mention  has  been  made  of  the  comparatively  large  number  of 
exhaustive  treatises  upon  genito-urinary  surgery  and  venereal  diseases 
which  have  appeared  since  1879,  and  they  may  be  appropriately 
named  at  this  point  as  follows: 

1880.     Otis:  Stricture  of  the  Urethra. 

1893.  P.  A.  Morrow:  System  of  Genito-urinary  Diseases  and 
Syphilis. 

1895.     White  and  Martin:  Genito-urinary  and  Venereal   Diseases. 

1898.  Bangs  and  Hardaway:  American  Text-book  of  Genito- 
urinary Diseases,  etc. 

1900.     Fuller:  Diseases  of  the  Genito-urinary  System. 

1902.    Morton:   Genito-urinary  Diseases  and  Syphilis. 

1905.     Deaver:  Monograph  on  the  Prostate. 

1907.  Greene  and  Brooks:   Diseases  of  the  Genito-urinary  Organs 

and  Kidneys. 

1908.  Watson   and    Cunningham:   Diseases   and    Surgery   of  the 

Genito-u rinary  System . 

1910.     New  Edition  of  Keyes.     Written  by  Edward  L.  Keyes,  Jr. 
1910.     Part  of  Keen's  Surgery  on  Genito-urinary  Diseases. 
1912.     Guiteras:    Urology. 

1912.  Garceau:  Monograph  on  Tumors  of  the  Kidney. 

1913.  Chetwood:  Practice  of  Urology. 


CONTRIBUTIONS  OF  AMERICAN  SURGEONS  TO   UROLOGY     35 

Translation  by  Bonney  of  the  work  of  Casper,  of  Berlin,  1910. 

The  work  of  Bumstead  and  of  Taylor,  of  New  York,  are  not  included 
in  this  list,  as  they  deal  only  with  venereal  disease. 

In  general,  it  may  be  said  that  all  of  these  works  are  of  high  merit 
and  of  great  value. 

In  addition  to  them  there  have  been  published  many  important  and 
admirable  monographs  upon  special  subjects  included  in  the  field  of 
urology. 

CONTRIBUTIONS  OF  AMERICAN  SURGEONS  TO  UROLOGY. 

The  members  of  the  medical  profession  whose  works  are  cited  in 
this  sketch  are,  with  three  or  four  exceptions,  those  who  are  no  longer 
living  or  who  have  retired  from  active  participation  in  the  work  of 
their  profession. 

The  author  of  this  chapter  recognizes  that  in  thus  limiting  its  personal 
history  he  does  not  render  full  justice  to  the  part  that  American  sur- 
geons have  taken  in  the  advancement  of  knowledge  of  Genito-urinary 
Surgery,  but  he  has  been  advised  to  follow  this  plan  by  those  having 
the  publication  in  hand,  and  as  he  thinks,  wisely  advised.  He  trusts 
to  be  excused  for  having  made  the  obvious  omissions  of  important 
work  done  by  his  colleagues  who  are  still  among  the  active  workers 
in  the  profession,  and  believes  that  they  will  readily  forgive  his  failure 
to  give  them  mention. 

Among  those  whose  works  receive  notice  below  there  are  three  still 
living:  Drs.  W.  H.  S.  Gouley  and  Edward  L.  Keyes,  Jr.,  of  New 
York,  and  Francis  S.  Watson,  of  Boston.  The  names  of  those  who 
have  died  are  as  follows: 

John  Ashhurst,  Jr.,  Philadelphia. 

Samuel  Alexander,  New  York. 

Henry  J.   Bigelow,   Boston. 

L.  Bolton  Bangs,  New  York. 

Tilden  Browne,  New  York. 

Dr.  Byford,  Chicago. 

John  P.  Bryson,  St.  Louis. 

Arthur  T.    Cabot,   Boston. 

George  Chismore,  San  Francisco. 

George  M.   Edebohls,   New  York. 

Dr.  Gilmore. 

William  Ingalls,  Boston. 

A.  Jackson,  Chicago. 

Fessenden  N.  Otis,  New  York. 

Dr.  Peasely,  New  York. 

Dr.  Pyle. 

Dr.  Peters,  New  York. 

Alex.  Stein,  New  York. 

Robert  Taylor,  New  York. 

Robert  Weir,  New  York. 

J.  William  W'hite,  Philadelphia. 


36      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

RENAL  SURGERY  IN  AMERICA. 

Nephrectomy.  Transperitoneal.— The  first  performance  of  the 
operation  of  nephrectomy  is  credited  by  Albarran  to  the  American 
surgeon  Walcott  in  1861.  The  operation  was  transperitoneal.  The 
patient  was  a  woman,  aged  fifty-eight  years.  She  had  cancer  of  the 
kidney.  She  succumbed  on  the  fifteenth  day  following  the  operation. 

Peasely. — The  second  nephrectomy,  also  a  transperitoneal  operation, 
was  done  by  an  American  surgeon  in  1868.  The  patient  was  believed 
to  have  an  ovarian  tumor,  and  the  operation  was  undertaken  under 
that  impression.  The  tumor  was  found  to  have  its  seat  in  the  kidney, 
and  that  organ  was  removed,  together  with  the  neoplasm.  This 
patient  also  died. 

Gilmore  performed,  in  1870,  one  of  the  earliest  nephrectomies,  and 
his  patient  recovered.  This,  too,  was  a  transperitoneal  operation. 
The  patient  was  a  woman  who  was  five  months  pregnant. 

Peters,  of  New  York,  in  1872,  did  another  nephrectomy,  the  patient 
in  this  case  dying  subsequent  to  it. 

Byford,  of  Chicago,  in  1878,  performed  the  first  successful  nephrec- 
tomy in  a  case  of  cancer  of  the  kidney.  This  operation  was  also  a 
transperitoneal  one.  The  patient  recovered. 

The  first  lumbar  nephrectomy  was,  as  is  well  known,  done  by  Simon, 
of  Heidelburg,  in  1869.  The  patient  recovered.  The  same  operation 
was  done  by  the  same  surgeon  again  in  1871.  This  patient  died.  The 
first  nephrectomy  in  England  was  done  by  Durham  in  1872.  The  first 
one  in  France  by  Le  Fort  in  1880. 

Nephrolithotomy. — The  first  performance  of  the  operation  of 
nephrolithotomy  is  of  uncertain  date.  Dr.  Desnos,  of  Paris,  in  a 
recent  and  admirable  historical  chapter  written  as  a  part  of  the 
Encyclopedic  Francaise  d'  Urologie,  quotes  from  the  Memoire  of 
Hevin,  in  which  it  is  stated  that  this  operation  was  performed,  in 
1633,  by  a  surgeon  named  Domonique  Marchettis,  the  patient  being 
an  English  consul.  The  patient  insisted  upon  having  the  operation 
done. 

The  procedure  was  carried  out  in  two  stages,  the  kidney  being 
exposed  on  one  day  and  entered  on  the  second  one.  Three  small 
calculi  were  extracted  from  its  interior  and  a  fourth  one  was  passed 
spontaneously  into  the  dressings  later.  The  latter  is  said  to  have  been 
the  size  of  a  date  stone.  The  patient  suffered  the  inconvenience  of 
having  a  permanent  renal  fistula,  but  recovered. 

A  similar  operation  is  said  to  have  been  done  by  Lafite  in  1734. 
The  operation  thereafter  was  condemned  and  passed  out  of  sight 
for  more  than  one  hundred  years. 

In  modern  times  one  of  the  first,  if  not  the  first,  surgeon  to  do  this 
was  an  American. 

William  Ingalls,  of  Boston. — Dr.  Ingalls,  a  member  of  the  surgical 
staff  of  the  Boston  City  Hospital,  removed  a  large  calculus  from  one 
of  the  kidneys  of  a  woman  by  a  lumbar  operation  which  he  had  deliber- 


RENAL  SURGERY  IN  AMERICA 


37 


ately  planned.  The  operation  was  done  October  8,  1872.  It  was  not 
reported  until  1882. 13  In  consequence  of  this  delay  the  English  surgeon 
Mr.  Morris  received  the  credit  of  being  the  originator  of  the  procedure 
in  modern  times.  He  published  his  first  cases  in  1881. 

Nephropexy. — The  operation  of  attaching  the  kidney  to  the  loin 
in  cases  in  which  the  organ  has  an  abnormal  mobility  and  more  or  less 
serious  symptoms  are  being  produced  by  it  originated  with  the  German 
surgeon  Hahn  in  1881.  Hahn's  operation  was  inadequate,  and  it  was 
not  until  the  following  year,  1882,  that  Bassini  for  the  first  time 
passed  sutures  through  the  capsula  vera  of  the  kidney  for  the  purpose 
of  fixing  it  to  the  posterior  wall  of  the  abdomen. 


FIG.  9. — Edebohls's  modification  of  the  operation  of  nephropexy. 

Cunningham.) 


(Watson  and 


Robert  Weir,  of  New  York  (1882).— The  method  employed  by 
Bassini  was  also  carried  out  by  Weir,  of  New  York,  in  the  same  year 
(1882) .  This  operation,  so  far  as  we  can  learn,  was  the  first  nephropexy 
performed  in  America. 

Numerous  modifications  of  the  technic  of  the  operation  have  been 
introduced  since  that  time.  Among  them  are  two  by  American 
surgeons.  The  first  of  these  is  that  of 

Edebohls,  of  New  York  (Fig.  9). — In  this  method  of  doing  the 
operation  the  kidney  is  decapsulated  and  the  sutures  are  applied  on 
either  side  of  the  organ  through  the  fibrous  capsule  which  they  traverse 
twice  in  order  to  give  a  more  firm  holding  ground  for  the  stitches. 


38      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

F.  S.  Watson,  of  Boston  (Fig.  10). — In  the  method  devised  by  Watson 
the  sutures  are  passed,  four  in  number,  through  the  substance  of  the 
kidney,  two  in  the  long,  and  two  in  the  tran s verse  axis  of  the  organ. 
The  capsule  is  split  through  the  length  of  the  posterior  border  of  the 
kidney. 


FIG.  10. — Watson's  modification  of  the  operation  of  nephropexy. 

Cunningham.) 


(Watson  and 


Bilateral  NephroUthotomy  at  one  Sitting  in  Certain  Cases  of 
Obstructive  Anuria. 

F.  S.  Watson,  of  Boston,  at  the  first  Congress  of  I'Association 
Internationale  d'Urologie,  held  in  Paris,  in  October,  1908,  made, 
as  one  of  the  reporters  en  the  subject  of  anuria,  a  plea  for  the  employ- 
ment of  bilateral  nephrolithotomy,  or  ureterolithotomy,  at  one  sitting 
in  certain  cases  of  calculous  anuria.  The  communication  forms  a 
part  of  the  reports  of  that  congress  issued  in  Paris  during  the  same 
year. 

Edward  L.    Keyes,  of  New  York  (New    York  Medical  Journal, 
June  16,  1894). — In  this  number  of  the  journal  is  a  valuable  communi- 
cation made  by  Dr.  Edward  L.  Keyes,  of  Newr  York,  on  the  subject 
of  nephritis  in  its  surgical  aspects. 


SURGERY  OF  THE  BLADDER  39 

SURGERY  OF  THE  BLADDER. 

Vesical  Calculus. —  Henry  J.  Bigelow.3 — Litholapaxy,  1878. — The 
most  noticeable  achievement  of  an  American  surgeon  in  the  field 
of  urology  is  that  to  which  its  author  gave  the  name  of  litholapaxy, 
intending  thereby  to  indicate  an  operation  for  crushing  vesical  calculus 
and  entirely  removing  it  from  the  bladder  in  one  and  the  same  sitting. 
The  first  account  of  Dr.  Bigelow's  method  was  published  in  the 
American  Journal  of  the  Medical  Sciences  in  1878.  Dr.  Bigelow  sub- 
sequently demonstrated  it  before  the  International  Medical  Congress 
in  London  in  1881. 

Before  the  introduction  of  the  operation  of  litholapaxy  the  method 
employed  when  treating  vesical  calculus  by  the  crushing  operation  of 
lithotrity  was  to  crush  the  calculus  for  as  short  a  time  as  possible  and 
to  leave  the  resulting  fragments  to  be  passed  out  by  the  natural  acts 
of  micturition.  The  calculus  was  finally  disposed  of  by  a  series  of 
successive  crushings  varying  in  number  according  to  the  size  and 
hardness  of  the  stone.  Five  minutes  was  the  longest  time  which  was 
thought  to  be  safe  to  continue  the  crushing  procedure  at  any  one 
sitting. 

The  operative  mortality  at  the  best — as,  for  example,  that  which 
occurred  in  the  hands  of  the  most  skilful  lithotritist  of  his  day,  Sir 
Henry  Thompson,  of  London — was  nearly  6  per  cent.,  wrhile  in  the 
hands  of  less  adroit  operators  it  was  nearly  10  per  cent.,  and  in  the 
case  of  patients  having  prostatic  obstructive  conditions  it  rose  to 
15  per  cent.,  and  even  higher. 

Bigelow  based  his  operation  of  litholapaxy  upon  the  belief  that  the 
bladder  would  tolerate  far  better  even  the  prolonged  manipulations 
in  it  of  smooth  round-ended  instruments  than  the  irritation  produced 
by  fragments  of  calculus  left  in  it  at  a  series  of  successive  sittings. 
If  he  wrere  correct  in  this  supposition,  and  if  the  means  could  be 
devised  for  emptying  the  bladder  entirely  of  fragments  immediately 
the  stone  had  been  crushed,  the  operative  mortality  should  be  greatly 
lessened.  There  remained,  in  order  to  test  his  theory,  therefore,  the 
devising  of  the  instruments  and  apparatus  by  which  these  things 
could  be  accomplished. 

The  discoveries  of  Otis  already  described,  with  respect  to  the  large 
size  of  the  normal  male  urethra,  had  opened  the  way  for  Bigelow  to 
devise  instruments  of  greater  power  for  the  crushing  of  vesical  calculi 
and  for  the  making  of  tubes  to  evacuate  the  fragments  of  stone  rapidly 
and  effectually.  Availing  himself  of  the  discoveries  of  Otis,  Bigelow 
devised  a  lithotrite  of  novel  form  and  greater  power  than  was  pos- 
sessed by  the  instruments  then  in  use,  and  contrived  an  apparatus  of 
most  cleverly  planned  and  beautifully  executed  character  for  evacu- 
ating the  fragments. 

The  special  features  of  Bigelow's  lithotrite  are  as  fellows:  (1)  The 
form  given  to  the  tip  of  the  female  blade  which  is  such  as  to  permit  it 
to  pass  over  obstructions  offered  by  an  hypertrophied  prostate  more 


40      SKETCH  OF  GENITO-URINARY  SURGERY  IN  AMERICA 


I 


FIG.  11. — Bigelow'a  evacuating  apparatus.     (Watson  and  Cunningham.) 


FIG.  12. — Jaws  of  Dr.  Bigelow's  lithotrite.     (Watson  and  Cunningham.) 


SURGERY  OF  THE  BLADDER 


41 


readily  than  any  other.     (2)  The  form  given  to  the  distal  or  crushing 
end  of  the  male  blade  of  the  instrument,  which  is  that  of  a  series  of 


FIG.  13. — Handle  of  Bigelow's  lithotrite,  showing  locking  mechanism  by  which  the 
blades  are  locked  upon  the  stone  or  released  from  it. 

diverging  planes  which  prevent  the  blades  from  becoming  clogged  with 
the  debris  of  the  calculus  during  the  crushing  of  it  (Fig.  12).     (3)  The 


FIG.  14. — Bigelow'a  evacuating  apparatus  withdrawing  fragments  of  calculus  from  the 
bladder.     (Watson  and  Cunningham.) 

mechanism  of  the  handle  of  the  instrument  which  is  such  as  to  avoid 
the  necessity  of  changing  the  operator's  hands  when  he  has  caught  the 


42      SKETCH  OF  GEM  TO-URINARY  SURGERY  IX  AMERICA 

calculus  and  desires  to  crush  it  (Fig  13).  This  was  necessary  with  the 
previously  constructed  lithotrites,  and  the  innovation  of  Bigelow  in 
this  detail  was  of  great  value.  (4)  Greater  strength  given  to  the 
blades;  this  is  such  as  to  make  it  impossible  to  break  them,  no  matter 
how  hard  they  are  screwed  together  upon  the  stone. 

The  features  of  the  evacuating  apparatus  are  the  following:  (1) 
The  placing  of  the  glass  trap  below  the  bulb  and  in  such  a  way  that  the 
fragments  of  the  stone  which  have  once  entered  it  cannot  be  washed 
out  of  it  again  by  the  returning  current  of  water  into  the  bladder. 
(2)  The  large  caliber  of  the  tubes  and  the  location  and  large  size  of  the 
eyes  of  them  at  their  distal  ends.  Also  the  raised  lip  on  the  posterior 
end  of  the  eye  which  prevents  the  slipping  past  it  of  the  fragments 
which  are  drawn  toward  it  by  the  current  of  water  that  sets  them  in 
motion.  (3)  The  straight  as  well  as  the  curved  form  of  tube,  the 
former  permitting,  when  it  can  be  introduced  into  the  bladder,  a  more 
rapid  evacuation  of  the  fragments  than  does  the  curved  tube.  The 
caliber  of  the  tubes  is  28  and  30  of  the  Charriere  scale  (Figs.  1 1  and  14). 

A  comparatively  short  time  of  its  employment  was  enough  to  make 
abundantly  clear  that  the  conception  of  the  author  of  this  new  opera- 
tion had  been  absolutely  correct.  The  operative  mortality  grew  at 
once  markedly  less  with  its  adoption  and  the  abandonment  of  the 
former  practice  of  successive  sittings. 

A  glance  at  the  records  of  this  operation  and  at  those  of  the  method 
of  performing  lithotrity  previously  and  also  of  the  results  of  the 
cutting  operations  at  once  demonstrates  the  superiority  of  litholapaxy, 
even  in  the  case  of  children  who  were  the  most  favorable  subjects 
for  the  lateral  lithotomy  operation. 

Two  series  of  American  surgeons  may  be  taken  as  examples  of  this 

fact.    They  are  those  of  Drs.  Edward  L.  Keyes  and  of  Arthur  T.  Cabot. 

Edward  L.   Keyes's  series  of  litholapaxy  operations:  Number  of 

cases,  157.    Operative  deaths,  7.    Recurrences,  25.    In  none  of  the 

fatal  cases  was  the  patient  less  than  fifty-eight  years  of  age. 

Arthur  T.  Cabot's  series  of  litholapaxy  operations:  Number  of 
cases,  179.  Operative  mortality,  4.3  per  cent.  Recurrences,  21. 
In  none  of  the  fatal  cases  was  the  age  of  the  patient  less  than  sixty 
years.  In  four  of  them  the  ages  of  the  patients  were  eighty-four, 
seventy,  seventy,  and  seventy  years  respectively. 

A  glance  at  the  large  number  of  cases  and  the  results  of  the  different 
methods  of  operation  will  give  a  just  idea  of  the  relative  value  of 
Bigelow's  operation  as  compared  with  other  methods.  Operative 
mortality  of  lithotrity  prior  to  the  introduction  of  Bigelow's  operation 
of  litholapaxy:  In  elderly  people,  from  15  per  cent,  to  20  per  cent. 
In  patients  aged  less  than  fifty  years,  about  9  per  cent,  to  10  per  cent. 

The  following  statistics  are  taken  from  Watson  and  Cunningham's 
Diseases  and  Surgery  of  the  Genito-urinary  System,  1908. 

Litholapaxy  Operations. — Number  of  cases,  17,736.  Operative  mor- 
tality, 2.4  per  cent.  Patients  of  all  ages.  In  2518  patients  under 
fifteen  years  of  age  the  operative  mortality  was  1.7  per  cent.  In  719 


SURGERY  OF  THE  BLADDER  43 

patients  between  fifteen  and  fifty  years  of  age  it  was  1.6  per  cent.    In 
2395  patients  over  fifty  years  of  age  it  was  4.04  per  cent. 

Lateral  Lithotomy. — Number  of  cases,  11,963.  Irrespective  of  age, 
operative  mortality  was  9.8  per  cent.  In  94  patients  over  fifty  years 
of  age  it  was  20.2  per  cent. 

Suprapitbic  Lithotomy.- — Number  of  cases,  3302.  Operative  mor- 
tality, irrespective  of  age,  was  13.2  per  cent.  In  378  patients  over 
fifty  years  of  age  it  was  25.4  per  cent. 

These  figures  speak  too  strongly  of  the  value  of  Bigelow's  method 
of  treatment  to  require  comment. 

There  are  several  factors,  however,  which  militate  against  the 
employment  of  litholapaxy  today  which  did  not  oppose  its  use  at  the 
time  of  its  introduction.  These  are:  (1)  The  marked  lessening  of  the 
operative  mortality  of  the  suprapubic  lithotomy  operation  as  com- 
pared with  former  times.  (2)  The  establishment  of  the  operations 
of  total  prostatectomy  which  allow  the  surgeon  to  remove  the  stone 
from  the  bladder  when  there  is  one  present  at  the  same  time  that  the 
prostate  is  taken  away,  and  thereby  there  is  secured  the  freedom  of 
obstruction  to  the  escape  of  urine  and  also  the  freedom  from  recurrence 
of  calculus.  Finally,  there  is  the  fact  that  many  surgeons  cannot  or 
do  not  acquire  the  delicacy  and  skill  which  are  requisite  for  the  success- 
ful performance  of  litholapaxy. 

Transperitoneal  Partial  Resection  of  the  Bladder. —  Dr.  Frank 
Harrington,  of  Boston.  This  method  of  treatment  in  certain  cases  of 
disease  of  the  bladder  was  first  practised  by  Rydygier  in  1887.  In 
1893  Harrington  first  performed  the  operation  in  America.  It  was 
but  little  employed  until  revived  by  the  Mayos  and  Judd  in  the  famous 
clinic  of  the  Mayo  brothers  in  Rochester,  who  have  used  the  procedure 
in  a  number  of  cases  of  vesical  tumors,  and  with  marked  success. 

Vesical  Tumors. — The  date  of  the  first  operation  performed  for  the 
removal  of  a  vesical  tumor  is  somewhat  uncertain.  The  earliest 
mention  that  has  been  found  of  such  an  operation  is  that  performed  in 
1635  by  Covillard.4  In  this  case  it  is  doubtful  whether  or  not  the 
tumor  removed  was  a  lobe  of  an  hypertrophied  prostate.  In  1750 
Warner  removed  through  the  female  urethra  a  large  polyp  of  the 
bladder.  The  patient  made  a  perfect  recovery. 

In  1890  the  most  complete  exposition  of  the  subject  of  vesical 
tumors  that  has  up  to  the  present  time  been  published  was  written 
by  the  most  brilliant  surgeon  of  France  in  the  field  of  genito-urinary 
surgery,  Professor  Albarran,  in  his  classic  work,  Tumeurs  de  la  Vessie. 

In  America  the  first  important  monograph  is  that  published  by: 

Alex.  W.  Stein,  of  New  York.20 — In  this  volume  there  are  set  forth 
among  much  else  that  is  of  interest  the  cases  of  vesical  tumor  in  which 
operations  had  been  done  prior  to  that  time. 

Watsoji,  of  Boston,  1884.24— Watson  published  an  article  on  the 
subject  of  vesical  tumors  in  which  he  added  10  cases  to  those  collected 
by  Stein  and  reported  1  in  which  he  had  operated  through  the  perineal 
boutonniere. 


44      SKETCH  OF  GENITO-VRINARY  SURGERY  IX  AMERICA 

The  earliest  operations  published  in  America  were  the  following: 
A.  R.  Jackson,  of  Chicago.14 
Ashhurst,  of  Philadelphia.2 
Ransohoff,   of  Cincinnati. 
Watson,  of  Boston.25 

Jackson's  case  has  some  unusual  features,  and  seems  worthy  of 
special  notice.  While  visiting  a  female  patient  one  day  he  found  a 
fleshy  mass  protruding  from  her  urethra.  As  he  was  examining  it 
it  was  withdrawn  into  the  bladder.  Jackson  directed  the  patient's 
husband  to  watch  for  its  reappearance,  and  told  him  should  it  again 
be  protruded  to  seize  it  with  a  pair  of  forceps  and  hold  it  until  he — 
the  doctor — should  arrive.  During  the  absence  of  the  surgeon  the 
tumor  was  again  pushed  into  view  through  the  urethra.  The  husband 
in  his  eagerness  to  observe  the  doctor's  orders  seized  upon  it  too 
forcibly  and  tore  a  part  of  it  off.  The  piece  that  was  thus  removed 
was  of  the  size  and  shape  of  the  forefinger. 

Subsequently  the  surgeon  arrived  and  dilated  the  urethra.  This 
enabled  him  to  reach  and  extract,  by  avulsion,  a  second  portion  of  a 
fleshy  mass  eight  inches  in  length  and  of  considerable  thickness.  The 
patient  made  an  excellent  recovery,  was  freed  from  her  former  symp- 
toms, and  reported  that  there  had  been  no  return  of  them  one  year 
after  the  performance  of  the  operation. 

Total  Cystectomy  (1887-1915).— The  first  operation  for  total 
removal  of  the  urinary  bladder  was  performed  in  1887  by  Bardenheuer. 
The  patient  did  not  survive.  In  1888  the  first  successful  operation 
of  the  kind  was  done  by  Pawfik,  of  Vienna,  in  the  case  of  a  woman 
having  vesical  carcinoma.  This  patient  survived  and  was  free  from 
recurrence  during  the  ensuing  fifteen  years  or  more. 

From  1887  to  the  present  time — 1915 — there  have  been  approxi- 
mately 80  total  cystectomies  reported  in  cases  of  vesical  tumor. 
The  operative  mortality  of  this  series  is  about  40.5  per  cent.  The 
operative  mortality  prior  to  1909  was  over  50  per  cent.  The  number 
of  cases  then  reported  was  approximately  60.  In  the  last  twenty 
operations  performed  since  then  there  has  been  a  striking  diminution 
of  the  operative  mortality,  which  is  sufficient  to  have  reduced  it  for 
the  total  number  of  the  cases  to  40.5  per  cent,  in  place  of  50  per  cent. 

Ureteral  Implantation. — Until  1895  the  ureters  were  either  implanted 
in  the  rectum,  in  the  vagina,  or  abandoned  in  the  wound;  and  with 
but  two  or  three  exceptions  this  was  the  practice  until  1905.  In  1895 
Vasilief  seems  to  have  been  the  first  surgeon  to  make  an  implantation 
of  the  ureters  to  the  skin  in  connection  with  the  operation  of  total 
cystectomy.  This  patient  recovered. 

In  1905  Watson,  of  Boston,23  proposed  a  radical  change  in  the 
method  of  performing  total  cystectomy  in  cases  of  vesical  tumor. 
Previous  to  that  time  it  was  almost  the  invariable  custom  to  implant 
the  ureters  in  one  or  the  other  of  the  locations  mentioned  above,  and 
to  do  this  at  the  same  time  as  that  at  which  the  bladder  was  removed. 

Study  of  the  causes  of  the  remarkably  high  mortality  attending  this 


SURGERY  OF  THE  BLADDER 


45 


FIG.    15. — Cup-shaped  hard-rubber  shield  of  Watson's  apparatus  for  permanent  renal 
drainage  through  the  loin.     (Wataon  and  Cunningham.) 


46      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 

operation  led  Watson  to  the  conviction  that  it  was  due  to  three  factors, 
these  being:  (1)  Shock  produced  by  the  prolongation  of  the  operation, 
rendered  necessary  if  the  urine  was  to  be  diverted  at  the  same  time 
at  which  the  bladder  was  removed.  (2)  Renal  infection  due  chiefly  to 
implanting  the  ureters  in  the  bowel  or  vagina,  but  though  in  far  less 
degree,  liable  to  be  invited  if  the  ureters  were  implanted  on  the  surface. 
(3)  Delaying  the  operation  until  the  patient's  powers  of  resistance 
were  lowered  too  far  to  permit  them  to  sustain  its  effects  and  until 
-there  was  every  probability  that  metastases  had  already  occurred. 


FIG.  17. — Watson's  apparatus  for  permanent  drainage  of  the  kidney,  showing  manner 
of  wearing  it.      (Watson  and  Cunningham.) 


He  therefore  proposed  that:  (1)  Ureteral  implantation  in  all  its 
forms  be  abandoned,  (2)  That  the  operation  be  applied  to  those 
patients  only  in  whom  malignant  disease  of  the  bladder  had  not 
advanced  to  a  late  stage,  but  was  in  its  early  development,  and  in 
whom  the  powers  of  resistance  were  still  good.  (3)  Above  all,  he 
proposed  that  the  operation  of  total  cystectomy  be  divided  into  two 
stages,  the  first  of  which  should  deal  with  the  diverting  of  the  urinary 
secretion  into  its  new  channel  and  that  step  alone,  for  accomplishing 
which  he  stated  his  preference  for  bilateral  nephrostomy  as  the 


HGERY  OF  THE  PROSTATE  47 

preliminary  step;  and  that  the  second  operation  should  be  the  removal 
of  the  bladder  at  whatever  time  it  might  be  appropriate  to  perform  it. 

He  further  described  and  illustrated  in  the  Annals  of  Surgery, 
September,  1907,  an  apparatus  designed  by  him  for  the  purpose  of 
keeping  a  patient  with  bilateral  renal  fistula3  in  the  loins  dry  and 
allowing  him  to  pursue  an  active  life  while  wearing  it.  (Figs.  1 5 
and  17.)  In  this  article  is  the  report  of  a  case  in  which  one  of  his 
patients  has  worn  such  an  apparatus  with  entire  comfort  during  seven- 
teen years,  and  has  been  actively  at  work  during  the  whole  time  and 
in  excellent  condition,  draining  all  the  urine  from  both  kidneys  into 
the  reservoirs  direct  through  nephrostomy  channels. 

In  only  one  instance  known  to  the  writer  has  the  plan  above  described 
been  adopted  exactly  as  it  was  set  forth  in  1905,  for  almost  all  who 
have  done  the  operation  have  employed  ureterostomy.  But  there 
have  been  a  number  of  cases  reported  in  w-hich  the  operation  has  been 
done  in  accordance  with  the  most  important  feature  of  that  plan, 
namely,  the  two-stage  operation;  and  so  far  as  the  writer  has  learned, 
there  has  been  no  operative  death  in  any  of  them.  It  would  therefore 
appear  that  his  claim  that  the  operative  mortality  would  be  markedly 
lessened,  if  his  proposal  were  adopted,  had  been  justified. 

SURGERY  OF  THE  PROSTATE. 

The  share  that  America  has  had  in  developing  the  surgery  of  the 
prostate  has  been  a  large  one,  and  it  was  in  this  country  that  it  was 
kept  alive  during  a  short  interval  in  which  it  had  been  abandoned 
elsewhere  in  the  world.  The  first  total  prostatectomy  done  through 
the  perineal  approach  was  performed  in  America.  The  suprapubic 
operation  of  prostatectomy  also  had  its  origin  in  America  almost 
simultaneously  with  its  birth  in  England,  and  some  of  the  best 
modifications  of  the  perineal  operation  have  originated  here.  Some 
of  the  earliest  writings  upon  the  operative  treatment  of  the  hyper- 
trophied  prostate  are  by  American  surgeons;  later,  some  of  the  most 
important  monographs  upon  the  surgery  cf  the  prostate  were  published 
by  Americans. 

Development  of  the  Surgical  Treatment  of  the  Hypertrophied 
Prostate. — The  earliest  instances  of  operations  by  which  parts  of  the 
obstructing  prostate  were  removed  were  those  in  which  they  were 
taken  away  either  accidentally  or  incidentally  to  lithotomy  operations. 
The  first  intentional  attempts  to  overcome  this  obstruction  to  the  exit 
of  urine  from  the  bladder  were  made  in  a  few  cases  by  tunneling  or 
cutting  through  the  median  lobe  of  the  enlarged  gland.  Among  these 
may  be  cited,  as  examples,  the  operations  of  John  Hunter,  in  1805. 
of  Sir  Everard  Home  in  1S35,  and  of  Brodie  in  1865.  In  1830  Chopart 
cut  through  the  median  lobe  with  a  sharp-pointed  lance  blade  passed 
through  a  catheter  with  an  open  distal  end.  In  1795  and  in  1800 
Dessault  and  Sir  William  Blizzard  respectively  removed  a  median 
lobe  and  a  lateral  lobe  in  the  course  of  lateral  lithotomy  operations. 


48      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  7.V  AMERICA 

Sir  William  Ferguson,5  in  the  London  Lancet,  January  1,  1870, 
makes  the  following  interesting  comment  upon  the  removal  of  the 
prostate:  "I  have  ventured  to  put  on  record  what  some  of  my  profes- 
sional brethren  may  have  hesitated  to  do  for  fear  that  they  may  have 
been  guilty  in  performing  their  operations  of  perpetrating  some 
rough  mechanism  not  in  accord  with  the  nicety  of  manipulation 
which  is  thought  so  essential  in  the  performance  of  the  master  handi- 
work of  surgery — lithotomy."  This  remark  of  Ferguson  was  applied 
to  his  proposal  to  remove  the  obstructing  parts  of  an  enlarged  prostate 
in  the  course  of  the  operation  of  lateral  lithotomy. 

Amussat  removed  a  mass  from  the  prostate  when  doing  a  suprapubic 
lithotomy  in  1830. 

In  1830  Guthrie11  definitely  proposed  division  of  the  bar  at  the  neck 
of  the  bladder. 

In  1856  the  operative  treatment  of  the  hypertrophied  prostate 
was  definitely  begun  by  the  French  surgeon  Mercier.16 

Merrier  urged  the  adoption  of  the  operations  of  division  of  the 
bar  at  the  neck  of  the  bladder  and  of  obstructing  median  lobes,  or  the 
removal  of  the  obstruction  to  urination  by  punching  out  a  piece  of  the 
median  lobe  by  means  of  instruments,  devised  especially  for  the 
purpose  by  him,  and  which  he  passed  through  the  whole  length  of  the 
urethra. 

W.  H.  S.  Gouley,9  of  New  York  (1873) .—The  operative  treatment 
of  the  hypertrophied  prostate  began  in  America  with  Gouley,  of 
New  York.  In  1881  the  writer  of  this  sketch  had  several  talks  with 
him,  during  which  Gouley  showed  him  specimens  of  parts  or  the 
whole  median  lobes  of  enlarged  prostates  which  he  had  removed  by 
an  operation  which  was  a  modification  of  that  of  Mercier,  whose  pupil 
Gouley  had  been.  The  modification  consisted  in  applying  the  method 
of  Mercier  through  a  perineal  boutonniere  incision  instead  of  through 
the  whole  length  of  the  urethra. 

More  important  yet,  however,  was  Gouley's  description  of  the 
operation  of  perineal  median  total  endo-urethral  finger  enucleation 
prostatectomy  which  he  sets  forth  in  his  work  entitled  Diseases  of 
the  Urinary  Organs,9  as  follows  (he  has  been  describing  partial  pros- 
tatectomy through  a  boutonniere  incision  in  the  urethra):  "The 
surgeon  should  endeavor  to  give  permanent  relief  by  a  procedure 
which  will  not  add  materially  to  the  dangers  of  the  preceding  steps. 
He  should  explore  the  prostate  through  the  artificial  opening,  and  if 
he  should  discover  a  median  enlargement,  or  isolated  tumors  (lobes), 
he  should  dilate  the  prostatic  sinus,  or  incise  it  laterally,  and  enu- 
cleate the  lateral  tumors,  and,  if  there  be  a  median  enlargement, 
excise  it,"  etc. 

In  1874  Bottini,  of  Padua,  introduced  his  operation  of  division 
of  the  median  obstruction  formed  by  a  middle  lobe  of  an  hypertrophied 
prostate  by  means  of  a  galvanocautery  blade  passed  through  the  whole 
length  of  the  urethra. 

In  1836  Parish,  of  Philadelphia,  describes  a  case  in  which  Dr.  Wistar, 


SURGERY  OF  THE  PROSTATE  49 

of  Philadelphia,  had  made  a  suprapubic  fistula  and  established  per- 
manent drainage  of  the  bladder  through  a  gold  tube  worn  in  the 
fistula.  In  this  case  urinary  obstruction  by  an  hypertrophied  prostate 
existed. 

Sir  Henry  Thompson,  of  London,  later  advocated  the  same  plan. 

In  1881  and  1883  Billroth  and  Leisrink  respectively  performed 
total  prostatectomy,  each  in  a  case  of  cancer  of  the  prostate.  These 
operations  were  carried  out  through  the  perineal  approach. 

In  1886  Belfield,  of  Chicago,  performed  his  first  suprapubic  pros- 
tatectomy. This  operation  was  a  partial  prostatectomy. 

In  1887  McGill,  of  Leeds,  England,  reported  several  prostatectomies 
in  which  in  some  instances  one  lateral  lobe  alone,  or  with  the  median 
lobe,  were  wholly  removed  by  finger  enucleation  through  a  suprapubic 
cystotomy  wound.  To  Belfield  and  to  McGill  the  suprapubic  operation 
properly  should  be  credited. 

In  the  following  year,  1888,  Watson,  of  Boston,  published  a  mono- 
graph, which  was  privately  distributed  among  his  colleagues,  in  which 
he  advocated  partial  prostatectomy  either  by  the  suprapubic  or  the 
median  perineal  route  by  removal  of  the  median  or  lateral  lobes,  wThen 
they  were  the  obstructing  parts  of  the  gland,  and  illustrated  a  galvano- 
cautery  instrument  devised  by  him  which  he  had  used  both  through 
the  suprapubic  and  the  perineal  median  incisions  for  the  purpose  of 
burning  through  the  median  obstruction — bar  at  the  neck  of  the 
bladder  or  lateral  enlargement  of  the  gland.  He  discarded  the  latter 
method  after  that  year,  having  done  it  in  the  course  of  his  first  partial 
suprapubic  prostatectomy  in  1889,26  and  also  a  total  perineal  median 
endo-urethral  prostatectomy.  The  last-named  case  was  not  published 
until  some  years  later. 

In  1889  Zuckerkandl31  described  his  total  perineal  prostatectomy 
through  a  perineal  transverse  crescentic  incision  and  separation  of  the 
rectum  from  the  prostate  and  finger  enucleation  through  an  incision 
in  the  posterior  surface  of  the  fibrous  sheath  of  the  gland. 

In  1890  Goodfellow,  of  San  Francisco,  performed  his  first  total 
prostatectomy  through  the  median  perineal  external  urethrotomy 
incision  and  endo-urethral  finger  enucleation.  His  first  report  of  his 
method  of  doing  this  operation  was  made  before  the  California  Academy 
of  Medicine  in  April,  1902.  He  read  other  communications  upon  this 
operation  and  reported  a  remarkably  successful  series  of  cases  in  which 
he  had  done  the  operation  on  78  patients,  with  an  operative  mor- 
tality of  but  2.5  per  cent. 

In  1892  Pyle19  describes  the  operation  of  Zuckerkandl  and  advocates 
its  employment. 

In  1894  Nicoll17  describes  the  removal  of  the  entire  gland  by  finger 
enucleation  through  a  perineal  incision  in  combination  with  the 
employment  of  the  suprapubic  cystotomy  incision  for  the  purpose 
of  exercising  downward  pressure  on  the  prostate  to  bring  it  near  the 
perineal  surface. 

Alexander1  advocated  the  combined  high  and  low  operation  and 

M  IT      I — 4 


50      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IX  AMERICA 

removal  of  the  gland  through  the  lower  route  after  freeing  it  from  its 
attachments  by  finger  enucleation  through  the  sides  of  the  prostatic 
urethra.  Subsequently  he  abandoned  the  upper  incision  and  employed 
the  median  perineal  avenue  of  approach  only. 

Fuller,  of  New  York,7  described  fully  the  suprapubic  total  pros- 
tatectomy. Also  in  his  treatise,  Diseases  of  the  Genito-urinary  Organs, 
1900. 

The  operation  described  by  Fuller,  in  1900,  Freyer,  of  London, 
without  the  slightest  justification,  endeavored  to  appropriate  as 
being  original  with  him  in  the  following  year,  1901. 6  His  claims  to 
priority  have  been  too  completely  disproved  to  call  for  further  notice. 

Thus  stood  the  history  of  the  development  of  the  operative  treat- 
ment of  the  hypertrophied  prostate  in  the  year  1900. 

One  of  the  interesting  features  connected  with  it  is  the  fact  that 
despite  the  able  and  vigorous  advocacy  of  the  above-named  radical 
procedures  by  a  number  of  distinguished  surgeons,  before  the  year  1900 
the  profession  turned  a  deaf  ear  to  their  counsel  and  would  have  none 
of  it.  In  some  instances,  indeed,  they  withdrew  their  patients  from 
the  care  of  certain  of  the  advocates  of  such  rash  measures.  Sir  Henry 
Thompson  and  Guy  on,  the  two  highest  authorities  upon  all  matters 
relating  to  genito-urinary  surgery,  pronounced  against  attempts  to 
relieve  patients  with  prostatic  hypertrophy  by  removal  of  the  gland, 
and  it  seemed  as  though  the  radical  surgical  treatment  might  be  doomed 
to  failure. 

There  was  another  reason  for  this  delay  in  the  establishment  of 
the  operation  of  total  prostatectomy.  This  was  the  proposal  of 
J.  William  White,  of  Philadelphia.30  Dr.  White  reported  at  the 
meeting  of  the  association  cited  above  the  results  of  experiments  which 
were  conducted  in  order  to  study  the  effects  of  castration  upon  the 
prostate  in  dogs,  and  advocated  partly  upon  the  basis  of  the  resulting 
atrophy  of  the  prostate-  in  these  animals  as  a  sequence  of  castration, 
his  proposal  to  treat  hypertrophy  of  the  prostate  in  the  human  being 
by  castration. 

In  the  same  year  Mears,  of  Philadelphia,  proposed  ligature  and 
resection  of  the  vasa  defTerentia  for  the  same  purpose. 

These  two  operations  were  presently  practised  on  a  large  scale  here 
and  in  England.  The  introduction  of  this  method  drewr  the  attention 
of  the  profession  for  a  number  of  years  from  the  more  radical  methods 
of  direct  attack  upon  the  prostate  itself,  and  hence  delayed  total 
prostatectomy  for  a  good  while.  The  castration  and  vas  resection 
operations  were  after  awhile  abandoned  because  of  having  been  found 
far  less  certain  and  reliable  in  their  results  than  total  prostatectomy, 
and  because  they  were  shown  by  Drs.  Arthur  Cabot  and  Wood  to 
have  a  surprisingly  high  mortality  and  to  be  followed  in  a  certain 
proportion  of  cases  by  mental  disturbances  of  more  or  less  severity. 

It  was  not  until  the  period  between  the  years  1900  and  1904  that  the 
operations  of  suprapubic  and  perineal  total  prostatectomy  became 
fully  established,  after  a  more  or  less  persistent  but  unavailing  effort 


SURGERY  OF  THE  URETHRA  51 

to  bring  them  into  use  had  been  made,  as  recounted  above,  by  a  number 
of  surgeons. 

The  final  establishment  of  the  low  and  the  high  total  prostatectomy 
operations  came  through  the  advocacy  of  the  perineal  operation  by  two 
brilliant  surgeons  in  France,  Albarran  and  Proust,  and  later  by  the 
able  and  skilful  advocacy  of  Young,  of  Baltimore,  in  America,  and 
in  England  by  the  advocacy  of  Freyer  (1901)  and  others  of  the  supra- 
pubic  method. 

SURGERY  OF  THE  URETHRA. 

Fessenden  N.  Otis,ls  of  New  York. — One  of  the  most  notable  con- 
tributions made  by  American  surgeons  to  genito-urinary  surgery  is 
that  of  Dr.  Otis,  of  New  York. 

Before  the  investigations  of  Otis  with  regard  to  the  normal  caliber 
of  the  male  urethra  there  was  no  standard  by  which  its  size  could  be 
estimated.  Various  assertions  were  made  with  regard  to  its  normal 
caliber,  but  always  there  was  a  difference  between  them.  One  esti- 
mated it  by  the  size  of  the  meatus,  another  gave  without  any  reason 
this  or  that  number  of  millimeters  for  its  normal  caliber.  There  was 
no  accord  in  the  various  estimates,  nor  any  data  by  which  to  deter- 
mine what  the  normal  caliber  actually  was. 

In  the  journal  cited  above  and  in  other  publications  subsequently, 
of  which  the  most  important  is  his  work  entitled  Practical  Clinical 
Lessons  on  Si^hiUs  and  Genito-urinary  Diseases,  published  in  1883, 
Dr.  Otis  gives  his  views  concerning  the  normal  caliber  of  the  male 
urethra,  the  relation  of  stricture  of  wide  caliber,  as  he  termed  narrow- 
ings  of  slight  extent,  to  gleet,  and  the  treatment  of  stricture  of  the 
urethra.  With  regard  to  the  latter,  he  believed  strongly  in  the  opera- 
tion of  internal  urethrotomy  properly  performed,  and  devised  a  new 
instrument  for  its  performance  which  is  superior  to  other  forms  of 
urethrotomes  in  all  cases  of  strictures  of  a  caliber  not  less  than  16  of 
Charriere  scale  of  measurement  (Fig.  18).  For  those  of  lesser  caliber 
he  advised  the  employment  of  the  instrument  of  Maisonneuve.  He 
also  designed  an  instrument  for  estimating  the  size  of  strictures.  It 
resembles  that  which  was  introduced  by  the  French  surgeon  Leroy 
d'Etiolles. 

Otis  laid  down  the  following  rules  with  regard  to  the  caliber  of  the 
urethra  and  the  treatment  of  stricture  by  the  cutting  operation: 

1.  That  the  meatus  cannot  be  taken  as  a  guide  to  the  size  of  the 
urethra  behind  it. 

2.  That  the  normal  caliber  of  the  male  urethra  is  much  larger  than 
was  previously  believed. 

3.  That  the  caliber  of  the  average  urethra  is  32  mm.  of  the  Charriere 
scale  of  measurement. 

4.  That  there  is  a  correspondence  between  the  circumference  of  the 
flaccid  penis  and  the  caliber  of  the  urethra  in  each  person  and  that 
both  these  measurements  differ  considerably  in  different  individuals. 

5.  That  there  are  but  very  few  urethra?  that  are  of  a  caliber  less 


52      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IN  AMERICA 


FIG.  18. — Otis's  urethrotome  and  steel  sound.     (Watson  and  Cunningham.) 


SURGERY  OP  THE  URETHRA  53 

than  28  of  the  Charriere  scale.  That  there  are  a  considerable  number 
of  a  calibers  larger  than  32  of  that  scale.  That  there  are  some  that  are 
as  large  as  40  of  that  scale. 

6.  That  the  caliber  of  the  urethra  of  a  penis  which  has  a  circum- 
ference of  3 1  inches  is  32  mm.,  and  that  for  every  quarter  of  an  inch 
of  increase  in  the  circumference  of  the  penis  there  is  a  corresponding 
increase  in  the  caliber  of  the  urethra  of  2  mm.     Thus  in  the  penis 
measuring  3|  inches  in  circumference  the  caliber  of  the  urethra  would 
be  34  mm.,  and  so  on.     So,  too,  if  the  penis  measures  less  than  3j 
inches  in  circumference,  there  is  a  correspondingly  smaller  caliber  of  the 
urethra  of  2  mm.  for  each  quarter  of  an  inch  in  the  circumference  of 
the  penis. 

7.  That  it  is  essential  to  completely  divide  strictures  if  one  is  to 
secure  a  permanent  result  by  the  operation  of  internal  urethrotomy. 
That  if  the  division  is  made  in  correspondence  with  the  caliber  of  the 
urethra  in  each  case,  this  caliber  being  established  by  carefully  taken 
measurements  beforehand,  and  if  the  incision  made  by  the  operation 
with  a  dilating  urethrotome,  such  as  that  of  Otis,  in  such  a  way  as  to 
ensure  the  restoration  of  the  strictured  parts  of  the  canal  to  the  normal 
caliber  of  the  special  urethra  in  which  it  is  made,  and  furthermore,  if 
the  incisions  thus  made  are  kept  open  subsequently  by  the  passage- 
of  a  sound  of  the  caliber  of  the  normal  urethra  every  second  day  after 
the  operation  until  no  blood  appears  after  the  withdrawal  of  the 
sound,  that  a  large  percentage  of  the  patients  will  be  permanently  cured. 

The  view  of  Otis  concerning  strictures  of  wride  caliber  were  shown 
by  Keyes,  Weir  and  others,  of  New  York,  to  be  erroneous.  It  was 
demonstrated  that  the  narrowings,  to  which  Otis  gave  this  name,  were 
in  most  instances  anatomical  folds  of  the  inner  lining  of  the  canal 
and  that  they  existed  in  every  urethra. 

Apart  from  the  last-named  factor  the  views  of  Otis  have  been 
shown  to  be  in  the  main  correct  and  their  establishment  produced  a 
decided  and  very  beneficial  eft'ect  in  the  treatment  of  stricture  of  the 
urethra.  His  discoveries  also  opened  the  way,  as  has  already  been 
said,  to  Bigelow  to  construct  his  instruments  for  the  performance  of 
the  operation  of  litholapaxy. 

Arthur  T.  Cabot. — Cabot  was  among  the  earlier  American  surgeons 
to  urge  the  employment  of  the  operation  of  resection  of  dense  strictures 
of  the  urethra  in  the  region  of  the  perineum,  and  reported  some  cases 
in  which  he  had  practised  this  operation  with  successful  results. 

Opposition  to  the  Treatment  of  Stricture  by  Electrolysis. — Edward 
L.  Keyes. — Keyes  rendered  valuable  service  by  his  opposition  to  the 
method  of  treating  stricture  by  electrolysis,  advocated  by  Newman, 
of  New  York. 

Operations  upon  Varicocele.  —  Edward  L.  Keyes. — Subcutaneous 
Ligature  in  Cases  of  Varicocele. — Keyes  modified  the  operation  of 
subcutaneous  ligature  of  the  veins  of  varicocele  by  a  clever  device 
which  is  described  in  his  second  edition  of  the  original  Van  Buren 
and  Keyes,  which  was  published  in  1888  (p.  453). 


54      SKETCH  OF  GENITO-URINARY  SURGERY  IN  AMERICA 

SURGICAL  INSTRUMENTS   AND  DEVICES  INTRODUCED  BY 
AMERICAN  SURGEONS. 

IF.    //.    S.    Gouley. —  The    Tunnelled  Sound  to    Secure   Immediate 
Dilatation   of   Stricture    (Fig.    19). — Gouley   devised   and    describes 


FIG.  19. — Gouley's  tunnelled  sound  with  filiform  guide.    (Watson  and  Cunningham.) 


SURGICAL  INSTRUMENTS  BY  AMERICAN  SURGEONS        55 

this  instrument  in  his  work,  Diseases  of  the  Urinary  Organs,  1873.8 
It  is  a  tunnelled  sound  which  may  be  threaded  onto  a  filiform  bougie, 
and  using  the  latter  as  a  guide,  can  be  passed  safely  through  a  tight 


FIG.  20. — Cabot's  tampon.     (Watson  and  Cunningham.) 

stricture  and  thus  secure  a  considerable  degree  of  dilatation  of  the 
stricture  in  any  case  in  which  it  is  so  narrow  as  only  to  allow  the 
passage  of  the  filiform. 

The   Keyes-Cabot   Tampon.  —  To   Arrest   Hemorrhage   after  Supra- 
pubic  Prostatectomy  (Fig.  20). 


FIG.  21. — Watson's  scissors  cautery.     (Watson  and  Cunningham.) 

Watson  introduced  several  surgical  devices  which  are  as  follows: 
A  curette  to  fit  the  finger  for  the  purpose  of  curetting  vesical  tumors 
through  a  perineal  boutonniere  incision.24 


50      SKETCH  OF  GEN  I  TO-URINARY  SURGERY  IX  AMERICA 

A  hard-rubber  drainage  tube  to  be  temporarily  worn  through  a 
perineal  boutonniere  and  which  permits  tamponing  to  arrest  hemor- 
rhage after  perineal  prostatectomy.29 


FIG.  22 


FIG.  23 

FIGS.  22  and  23. — Watson's  bladder  speculum  closed  and  open.     (Watson  and 

Cunningham.) 

A  scissors  cautery  to  remove  vesical  tumors  through  a  suprapubic 
cystotomy  incision.27 

A  bladder  speculum.28 

A  galvanocautery  prostatectatome  to  be  applied  either  through  a 
perineal  boutonniere  or  suprapubic  incision.29 


VENEREAL  DISEASES  57 

Apparatus  for  receiving  urine  from  permanent  renal  fistulse  in  the 
loins;  already  mentioned  earlier  in  the  chapter  (Figs.  21,  22  and  23). 
Tilden   Browne's  Modification  of  the  Cystoscope. 

VENEREAL  DISEASES. 

The  most  important  single  contribution  to  the  treatment  of  syphilis 
contributed  by  an  American  surgeon  is  that  of  Dr.  Edward  L.  Keyes, 
of  New  York. 

To  the  effective  advocacy  of  Dr.  Keyes  the  profession  in  America 
owes  more  than  to  anyone  else  the  plan  of  employing  mercury  in  small 
tonic  doses  during  long  periods  instead  of  the  method  of  treatment  by 
large  doses  of  the  drug  which  formerly  prevailed  and  to  which  practice 
much  of  the  opposition  to  its  use  was  due.  Dr.  Keyes  was  a  persistent 
advocate  of  the  tonic  dose  mercurial  treatment  of  syphilis,  and 
established  its  value  in  the  face  of  strong  opposition.22 

Robert  Taylor,  of  New  ^foYk.—Genito-urinary  and  Venereal  Dis- 
eases.111— In  this  excellent  volume  Dr.  Taylor  includes  the  surgical 
diseases  of  stricture  and  of  the  prostate  and  other  organs  of  the  genito- 
urinary system,  but  470  out  of  732  pages  of  which  the  volume  is  com- 
posed are  devoted  to  venereal  diseases,  or  nearly  two-thirds  of  the 
whole  volume.  The  work  is  far  more  a  treatise  on  venereal  disease 
than  on  the  surgical  maladies  of  the  genito-urinary  system,  and  has 
usually  been  so  regarded. 

BIBLIOGRAPHY. 

1.  Alexander:  New  York  Mod.  Jour.,  1896,  Ixiii,  171. 

2.  Ashhurst:  Phila.   Med.  Times,  April  15,   1872. 

3.  Bigelow:  Am.  Jour.  Med.  Sc.,  1878. 

4.  Covillard:  Obs.  latro-chir.,  p.  93. 

5.  Ferguson:  Lancet,  January  1,  1870. 

6.  Freyer:  Brit.  Med.  Jour.,  1901,  ii,  125. 

7.  Fuller:  Jour.   Cut.   and   Genito-Urin.  Dis.,  1895,  ii,  239;    also   treatise,  Dis.  of 
Genito-Urin.  Organs,  1900. 

8.  Gouley:  Dis.  of  the  Urin.  Organs,  New  York,  1873. 

9.  Gouley:  Dis.  of  the  Urin.  Organs,  1873. 

10.  Gross:  On  the  Urinary  Organs. 

11.  Guthrie:  Anat.  and  Dis.  of  the  Neck  of  the  Bladder,  1830. 

12.  Harrington:  Ann.  of  Surg.,   October,    1893. 

13.  Ingalls:  Boston  Med.  and  Surg.  Jour.,  March  25,  1882. 

14.  Jackson:   Boston  Med.  and  Surg.  Jour.,  August  25,  1870. 

15.  Keyes:  New  York  Med.  Jour.,  June  16,  1894. 

16.  Mercier:  Recherches  sur  les  Maladies  des  Organes  Urinaries,  Paris,  1856. 

17.  Nicoll:  Lancet,  April  14,  1894. 

18.  Otis,  Fessinden   N.:  Calibration  of  the  Male  Urethra  and  its  Influence  on  the 
Treatment  of  Stricture,  New  York  Med.  Jour.,  1872,  xv,  152. 

19.  Pyle:  New  York  Med.  Rec.,  1892,  xlii. 

20.  Stein:  A  Study  of  Tumors  of  the  Bladder,  1881. 

21.  Taylor:  Genito-Urin.  and  Ven.  Dis.,  1904,  ^d  ed. 

22.  Van  Buren  and  Keyes:  Genito-Urin.  Dis.  and  Syph.,  1877. 

23.  Watson:  Ann.  of  Surg.,   December,   1905. 

24.  Watson:  Boston  Med.  and  Surg.  Jour.,  October  30,  1884. 

25.  Watson:  Boston  Med.  and  Surg.  Jour.,  October,  1884,  p.  414. 

26.  Watson:  Boston  Med.  and  Surg.  Jour.,  March  7,  1889. 

27.  Watson:  Lancet,    October,    1890,   p.   808. 

28.  Watson:  Lancet,  October,  1890,  p.  809. 

29.  Watson:  The  Oper.  Treat,  of  Hypertro.  of  Pros.,  1888. 

30.  White:  Trans.  Am.  Surg.  Assn.,  1893,  xl,  167. 

31.  Zuckerkandl:  Wiener  med.  Presse,  1889,  xxx,  857-902. 


CHAPTER  II. 
THE  CYSTOSCOPE  AND  ITS  USE. 

BY  LEO  BUERGER,  M.A.,  M.D. 

THE  interior  of  the  bladder  can  be  brought  into  view  either  with  the 
cystoscope  or  with  the  endoscope.  A  cystoscope  is  a  tube  carrying  a 
system  of  lenses  (telescope)  by  virtue  of  which  a  field  much  larger  than 
the  lumen  of  the  tube  can  be  seen.  An  endoscope  is  a  simple  metal  tube 
through  which  light  can  be  thrown  to  allow  of  inspection  by  direct 
vision. 

Cystoscopes  may  be  classified,  according  to  the  lens  system  em- 
ployed, into  two  types:  the  direct,  in  which  the  plane  of  the  field  or 
view  is  perpendicular  to  the  axis  of  the  telescope  or  cystoscope,  and  the 
indirect  or  prismatic,  in  which  the  field  is  deflected  90°. 

The  Direct  Cystoscope. — Through  the  work  of  Nitze,  an  optical 
system  was  developed,  by  means  of  which  a  comparatively  large  portion 
of  the  vesical  interior  can  be  visualized  through  a  very  small  tube,  the 
field  of  view  being  many  times  greater  than  that  obtainable  with  the 
endoscope.  Fig.  24  illustrates  the  actual  field  of  vision  (x  y)  through 
an  endoscopic  tube,  and  that  (a  b)  of  a  Nitze  telescope,  and  shows  how 
they  are  projected  by  the  eye  to  X  Y  and  A  B  respectively. 

Properties  of  the  Nitze  (Direct)  Optical  System. — Enclosed  in  a  narrow 
tube  there  are  three  essential  lenses:  an  objective  lens  or  lenses,  a 
middle  or  inverting  lens,  and  an  ocular  or  eye-piece  (Fig.  25) .  The  chief 
physical  properties  of  such  a  system  are  (1)  amplification  of  the  field  of 
vision,  the  picture  being  in  correct  or  upright  position,  and  (2)  magni- 
fication of  objects  as  they  approach  the  telescope,  the  focus  being 
practically  correct  at  all  distances  (universal  focus). 

1.  Amplification  of  the  Field. — The  objective  is  a  lens  of  very  short 
focal  distance,  which  produces  a  minute,  real  and  inverted  image  of  a 
comparatively  large  field  (Fig.  25,  a  6)  at  the  distal  end  of  the  tube 
(Fig.  25,  a  B).  This  image,  which  is  too  small  to  be  seen  by  the  naked 
eye,  is  transplanted  by  the  middle  lens  to  the  eye  or  ocular  end  of  the 
telescope,  where  it  can  be  enlarged  by  the  ocular  lens.  The  eye  sees 
an  enlarged,  virtual  image,  whose  apparent  size  depends  upon  the  diam- 
eter of  the  telescope  and  the  magnifying  power  of  the  ocular  (Fig.  25, 
A  B).  In  short,  a  field  much  larger  than  the  capacity  of  the  tube  is 
brought  into  view. 

The  illuminated  disk  that  is  seen  when  the  objective  of  the  telescope 

is  held  toward  the  sky  may  be  called  the  "inner  field,"  or  apparent  or 

virtual  image.    The  size  of  the  true  "  outer  field,"  or  object,  varies  with 

the  distance  of  the  objective  lens  from  the  plane  upon  which  the  tele- 

(58) 


THE  DIRECT  CYSTOSCOPE 


59 


scope  looks.  The  virtual  capacity  of  such  a  system  can  be  represented 
by  a  cone  whose  base  is  at  infinity  and  whose  apex  is  at  the  centre  of  the 
objective  lens  (Fig.  25,  a  c  b). 

2.  Magnification. — If  such  a  telescope  be  held  toward  the  sky  and  a 
small  object  be  interposed,  the  following  facts  will  be  noticed:  (1)  that 
the  illuminated  disk  or  inner  field  remains  the  same ;  (2)  that  the  size 
of  the  interposed  object  varies,  becoming  larger  as  it  approaches  the 


FIG.  24. — Comparison  of  actual  field  inspected  with  a  simple  endoscopic  tube  (x  y  =  X  Y) 
and  with  a  direct  telescope  (a  b  =  A  B). 

objective,  and  smaller  as  it  recedes;  (3)  that  when  the  object  is  made 
to  approach  closely  but  a  small  portion  of  it  can  be  seen,  and,  conversely, 
at  greater  distances  more  and  more  of  it  comes  into  view. 

Fig.  26  will  illustrate:  Let  0  be  a  telescope,  the  objective  lens  of 
which  produces  an  inverted  image  (a  /3)  of  the  field,  a  b  (a  a,  b  b  in  full- 
face  view)  and  a  c  b  the  visual  angle  of  the  system.  Given  an  ocular  of 
such  power  that  the  size  of  the  object  (a  6)  and  of  the  enlarged  image  or 


FIG.  25. — Direct  telescopic  system,     a  b,  outer  field;  AB  inner  field;  angle  acb 
visual  angle  aB  =  small  inverted  image  produced  by  the  objective  lens. 


virtual  image  (A  B}  will  be  identical.  In  other  words,  let  a  b  be  situated 
at  a  point  (7)  where  it  appears  as  large  as  it  really  is  (a  b  =  A  ft).  At 
II  only  a  portion  (a'  &')  will  be  seen.  This,  however,  takes  up  the  same 
space  in  the  tube  (a  0) ,  and  therefore  will  also  be  seen  as  large  as 
A  B-,  therefore  a'  V  is  equal  to  A'  B'.  At  777,  a"  b"  =  A"  B"; 
at  IV,  a'"  b'"  =  A'"  B"'.  The  virtual  image  (A  B},  or  "inner  field," 
seen  through  the  telescope  always  remains  the  same,  but  the  size  of  the 


60 


THE  CYSTOSCOPE  AND  ITS   UXE 


outer  or  actual  field  rapidly  diminishes  as  it  approaches  the  lens.  A 
small  field  at  a  short  distance  is  made  to  occupy  the  same  amount  of 
space  in  the  virtual  (inner)  field  as  a  large  one,  and  is  therefore 
enlarged. 


bb 


atab 


ata'b 


FIG.  26. — Diagrammatic  explanation  of  the  magnifying  power  of  the  telescope. 

This  system  (the  direct,  non-prismatic)  is  employed  in  all  direct 
telescopic  cystoscopes,  such  as  the  modifications  of  Brenner,  Brown, 
Lewis,  and  in  Buerger's  universal  urethroscope. 

The  Prismatic  (Indirect)  Optical  System.— In  order  to  bring  the 
trigone  of  the  bladder  more  readily  into  view  a  right-angled  prism  is 
placed  in  front  of  the  objective.  The  prism's  silvered  hypothenuse 
acts  like  a  mirror,  deflecting  the  whole  field  90°,  and  inverting  the 


\ 


FIG.  27. — The  effect  of  the  right-angled  prism  in  inverting  the  far  (north)  and  near 
(south)   points  of  the  field. 

upper  (north)  and  lower  (south)  parts  of  the  picture,  no  change  taking 
place  as  far  as  left  and  right  are  concerned  (Figs.  27  and  28). 

This  optical  system  was  first  used  in  the  N'itze  cystoscope  (Figs.  28 
and  29) .    Resembling  a  metallic  catheter,  this  consists  of  a  shaft,  a  beak, 


CORRECT  VISION  SYSTEMS 


61 


and  an  ocular  portion.  The  shaft  contains  the  optical  system.*  At 
the  point  A  there  is  a  window  through  which  the  rays  from  the  object 
or  field  enter.  The  beak  carries  a  detachable  electric  lamp  for  illumina- 
tion of  the  bladder.  Near  the  ocular  is  the  apparatus  for  attaching  the 
electric  coupling  B.  The  current  is  transmitted  through  the  shaft  to 
the  beak  by  way  of  an  enclosed  wire,  the  circuit  being  completed  by  the 
metal  wall  of  the  instrument  itself.  This  instrument  is  known  as  the 
Xitze  examining  or  observation  cystoscope  (Fig.  29). 


->* 

N  —     •„ 

FIG.  28. — Nitze  cystoscope  in  longitudinal  section  viewing  the  arrow  in  the  floor  of  the 
bladder,  the  picture  seen  by  the  eye  being  inverted. 

Correct  Vision  Systems. — To  overcome  the  disturbing  effects  of 
the  inversion  of  the  picture  E.  R.  Frank7  added  a  second  or  rectifying 
prism  to  the  ocular.  The  most  improved  methods  are  those  of  Ringleb 
(used  in  some  Continental  instruments)  and  Buerger.  In  most  of  the 
American  cystoscopes  the  system  described  by  Buerger5  has  been 


FIG.  29. — Nitze  cystoscope,  showing  sheath  with  lamp,  prism  (A),  contact  (B),  and  fork 
coupling  (C)  for  electric  connection. 

adopted.  A  modified  Wapplerjprism  (a  hemispherical  lens  with  one 
plain  side)  is  the  objective,  and  six  middle  achromatic  lenses  and  an 
ocular  make  up  the  rest  of  the  system.  The  objective  lens  brings  about 
one  reversal  of  the  picture,  the  middle  lenses  two  additional  reversals. 
In  the  sense  of  north  and  south  (Fig.  30)  the  prism  causes  another 
inversion,  so  that  we  have  a  total  of  four  reversals  for  the  north  and 


*  Note  that  two  lenses  are  employed  in  the  objective  instead  of  one  as  in  our  diagrams. 
The  second  lens  tends  to  overcome  spherical  aberration. 


62 


THE  CYSTOSCOPE  AND  ITS   USE 


south  points  and  three  reversals  for  the  east  and  west  points  (Fig.  31). 
This  naturally  results  in  the  production  of  an  image  whose  north  and 
south  poles  are  upright  and  correct,  and  whose  east  and  west  points  are 
reversed.  The  interchange  of  these  points  is  then  brought  about  by  a 


FIG.  30. — The  course  of  the  rays  from  north  and  south  points  through  the  corrected  lens 
system,  showing  four  reversals  of  the  arrow,  the  result  being  an  upright  picture. 

simple  reversing  prism  of  90°  (Fig.  31)  that  is  placed  in  front  of  the 
ocular.  This  system  gives  a  larger  field  of  vision  and  a  great  deal  more 
light  than  is  obtainable  in  any  other  telescopic  system. 


Hi*  looking.daKn  at  Object 


FIG.  31. — The  course  of  the  rays  in  the  same  telescope  from  east  and  west,  showing 
three  reversals  through  lenses,  one  reversal  by  the  prism,  the  final  result  being  non- 
inversion. 

Since  a  corrected  or  upright  picture  greatly  facilitates  cystoscopic 
work,  the  above  optical  system  has  been  almost  universally  adopted  in 
the  United  States.  In  all  future  descriptions,  therefore,  the  use  of  this 
system  will  be  understood. 


CYSTOSCOPES. 

In  addition  to  the  classification  into  direct  or  indirect  varieties, 
cystoscopes  may  be  grouped  as  examining  (observation)  and  catheter iz- 
ing  instruments,  according  to  their  special  function. 

Direct  Cystoscopes. — This  type  had  been  used  by  Nitze  for  purposes 
of  examination  before  he  had  improved  the  cystoscope  through  the 
addition  of  a  prism.  Brenner,  by  adding  a  catheter  channel,  was  the 
first  to  employ  this  instrument  for  catheterization  of  the  ureters. 
F.  Tilden  Brown  improved  this  by  separating  the  telescope  from  the 
sheath,  the  former  carrying  channels  for  two  catheters  for  synchronous 
ureteral  catheterization  (Fig.  32).  Later,  Brown  modified  this  instru- 
ment by  cutting  an  additional  fenestra  into  the  concave  aspect  of  the 
beak  and  by  rearranging  the  lamp.  This  permitted  of  the  introduction 
and  the  application  of  a  telescope  of  the  indirect  type  for  ureteral 


CYSTOSCOPES 


63 


catheterization.  To  this  instrument  he  applied  the  name  composite 
cystoscope.  Bransford  Lewis  developed  a  similar  instrument,  calling  it 
universal  cystoscope. 

The  field  of  vision  of  the  cystoscope  illustrated  in  Figs.  23,  24  and  25 
will  be  seen  to  encompass  a  cone  whose  apex  is  at  the  objective  and 
whose  base  lies  in  planes  perpendicular  to  the  axis  of  the  telescope. 
"When  introduced  into  the  bladder  such  a  cystoscope  would  look  directly 


FIG.  32. — The  beak  of  the  Brown  direct  catheterizing  cystoscope  showing  lamp,  objective 
end  of  telescope  and  two  catheters  projecting. 

at  the  posterior  wall.  For  a  thorough  inspection  of  the  bladder  it  has 
certain  disadvantages  which  have  resulted  in  its  being  gradually  sup- 
planted by  the  prismatic  type  of  instrument.  Thus,  it  is  necessary  to 
make  wide  excursions  with  the  instrument  to  inspect  the  interior  of 
the  bladder.  Although  this  is  feasible  without  much  distress  to  the 
patient  in  the  female,  it  is  almost  impossible  to  make  adequate  excur- 
sions in  the  case  of  the  male.  Fig.  33  illustrates  the  wide  sweep  that 


FIG.    33. — Wide  excursion  of  the  direct  cystoscope  in  order  to  bring  the  posterior  wall 
of  the  bladder  into  view  with  a  direct  cystoscope. 

must  be  made  with  the  shaft  of  the  instrument  in  order  to  bring  a  con- 
siderable portion  of  the  bladder  interior  into  view.  The  prismatic 
cystoscope  is  not  open  to  this  objection,  since  by  rotation  about  its 
long  axis  (Fig.  34)  an  annular  band,  including  roof,  lateral  walls,  and 
floor  of  the  bladder,  can  be  seen.  By  an  inward  or  outward  movement 
along  its  long  axis  combined  with  rotation,  almost  the  whole  of  the 
bladder  interior  can  be  inspected. 


64 


THE  CYSTOSCOPE  AND  ITS   USE 


FIG.  34. — Annular  band  around  the  whole  bladder  brought  into  view  by  rotation 
of  the  prismatic  cystoscope  on  its  long  axis,  very  slight  rotation  bringing  the  fields 
/,  //,  and  ///  into  view. 


B 


:iii\mwtvnffim 


FIG.  35 


FIG.  36  FIG.  37  FIG.  38 

FIGS.  35,  36,  37  and  38. — Diagrammatic  drawings  demonstrating  that  only  objects  lying 

in  planes  perpendicular  to  the  axis  of  the  direct  cystoscope  suffer  no  distortion. 


CYSTOSCOPES  65 

Another  disadvantage  of  the  direct  system  is  the  fact  that  only 
objects  that  lie  in  planes  perpendicular  to  the  long  axis  of  the  telescope 
escape  the  effects  of  distortion.  Figs.  35,  36,  37  and  38  demonstrate 
this  fact,  the  hair-pin  having  a  grotesque  appearance  when  telescope 
and  object  are  parallel.  When  the  most  important  portion  of  the 
bladder  is  viewed,  namely,  the  trigone  and  ureteric  orifices,  the  ocular 
end  of  the  instrument  must  be  raised  so  as  to  depress  the  objective 
against  the  floor  of  the  bladder  (Fig.  66).  Under  these  circumstances 
the  plane  of  the  trigone  is  almost  parallel  to  that  of  the  long  axis  of  the 
instrument.  The  trigone  and  ureters,  therefore,  will  come  but  poorly 
into  view.  The  prismatic  telescope  will  give  a  perfect  picture  of  this 
region. 

The  Prismatic  or  Indirect  Cystoscope. — Here  the  eye  of  the  observer 
may  be  regarded  as  transferred  from  the  region  of  the  ocular  to  the 
objective,  where  it  looks  in  a  direction  perpendicular  to  the  shaft  of  the 
instrument  (Figs.  28  and  50). 


FIG.  39. — Otis-Brown-Nitze  cystoscope. 

For  a  long  time  the  prismatic  cystoscopes  were  unpopular  in  the 
United  States  because  of  the  difficulty  in  interpreting  the  inverted 
picture.  Since  the  introduction  of  the  corrected  systems1  the  advan- 
tages of  the  prismatic  type  have  become  evident  to  most  all  cysto- 
scopists,  so  that  the  indirect  system  is  most  widely  used  today. 

The  most  generally  useful  examining  cystoscopes  are  the  Buerger, 
Otis-Nitze,  or  Nitze  (Fig.  39).  The  first  will  be  described  under 
Catheterizing  Cystoscopes. 

Otis-Nitze  Cystoscope. — The  Nitze  evacuating  cystoscope  for  pur- 
poses of  observation  was  improved  by  Otis  and  Brown  by  the  use  of  a 
Wappler  hemispherical  lens  and  a  change  in  the  pattern  of  the  beak. 
The  Otis-Nitze  consists  of  a  sheath  carrying  a  lamp,  a  fenestra 
through  which  the  objective  looks,  two  irrigating  faucets  at  the 
ocular  end,  and  an  observation  telescope.  After  removal  of  the  tele- 
scope the  sheath  can  be  employed  for  irrigation  of  the  bladder.  Where 
an  examining  cystoscope  of  smaller  caliber  than  the  Buerger  instrument 
is  desired,  this  cystoscope  will  be  found  serviceable. 

Catheterizing  Cystoscopes. — In  order  to  provide  for  the  collection 
of  urine  from  each  kidney  separately,  the  examining  cystoscopes  had  to 
5 


66  THE  CYSTOSCOPE  AND  ITS   USE 

be  modified  so  as  to  carry  catheters  that  could  be  inserted  into  the 
ureteral  orifices  under  the  guidance  of  the  eye. 

Direct  Catheterizing  Cystoscopes. — Brenner  converted  the  direct  cysto- 
scope  into  a  catheterizing  instrument  in  1887  by  placing  a  channel  for 
one  ureteral  catheter  below  the  telescope. 

F.  Tilden  Brown  improved  the  Brenner  cystoscope  by  separating 
the  sheath  and  the  telescope,  the  latter  carrying  the  catheter  bed  or 
channels  (Fig.  32).  The  sheath  carries  the  lamp  and  provisions  for 
electric  contact,  and  is  closed  with  an  obturator  before  introduction 
into  the  bladder. 

Indirect  Catheterizing  Cystoscopes. — All  instruments  of  this  type  are 
based  upon  the  Nitze  instrument,  in  which  it  was  found  necessary  to 
add  a  mechanism  for  deflecting  the  catheters  so  that  they  would  have 
the  proper  direction  for  insertion  into  the  ureters.  Albarran's  deflector, 
or  finger,  which  could  be  elevated  or  depressed  by  a  mechanism  situated 
at  the  ocular  end  of  the  instrument,  is  the  most  useful  device  of  this 
kind,  and,  in  somewhat  modified  form,  is  still  in  use  today. 

The  Nitze- Albarran  Cystoscope. — In  America  this  instrument  possesses 
merely  historical  interest.  It  is  the  Nitze  observation  instrument  with 
provision  for  the  introduction  of  one  or  two  ureteral  catheters  that 
may  be  passed  through  a  separate  channel  in  the  shaft  of  the  instru- 
ment. Because  of  many  mechanical  disadvantages  this  instrument  has 
been  discarded  almost  completely  in  the  United  States,  and  has  been 
supplanted  by  the  Buerger  cystoscope. 

The  Buerger  Catheterizing  Cystoscope.* — This  instrument  (Fig.  40) 
consists  of  four  parts,  the  sheath,  the  obturator,  the  observation  tele- 
scope, and  the  catheterizing  telescope.  The  sheath  is  circular  on  cross- 
section,  bears  a  very  short  lamp  at  its  end,  and  possesses  a  large  fenestra 
or  window  behind  the  lamp.  Its  caliber  is  about  24  French,  f  The 
obturator  closes  the  working  aperture  perfectly.  The  observation 
telescope  is  large,  but  does  not  completely  fill  the  sheath,  room  being 
left  for  irrigation.  The  catheterizing  telescope  combines  in  one  piece 
the  optical  apparatus,  the  mechanism  for  deflection  and  the  catheter 
grooves  or  beds.  At  the  objective  end  the  catheters  may  be  fastened 
by  a  clip;  at  the  ocular  end  there  are  two  catheter  channels  through 
which  the  catheters  emerge.  These  are  provided  with  rubber  tips  or 
nipples  that  firmly  grasp  the  catheters  and  prevent  the  escape  of  fluid 
from  the  bladder.  A  large  deflector  or  catheter  lift  is  implanted 
near  the  objective. 

This  instrument  presents  the  following  advantages:  the  employ- 
ment of  a  catheter  for  washing  the  bladder  is  unnecessary,  the  sheath 
serving  this  purpose;  because  of  its  small  size,  its  round  shape,  the 
smoothness  in  the  region  of  the  beak  and  window,  the  introduction  of 
this  instrument  is  easy,  and  injury  to  the  deep  urethra  is  avoided; 
synchronous  ureteral  catheterization  with  two  No.  6  French  catheters  is 

*  Sold  under  the  name  of  Brown-Buerger  Cystoscope,  because  the  sheath  principle 
popularized  in  the  United  States  by  Brown  was  adopted.  (This  principle  had  been  intro- 
duced by  Nitze  in  his  "Evacuation  Cystoscope.") 

t  Recently,  Buerger  has  devised  a  smaller  (21  Fr.)  double  catheterizing  cystoscope 
carrying  2  No.  6  French  ureteral  catheters.  The  design  is  the  same  as  that  of  the  above. 


CYSTOSCOPES 


67 


possible,  and  the  telescope  and  sheath  may  be  removed,  leaving  the 
catheters  in  the  ureters;  irrigation  of  the  bladder  may  be  very  rapidly 
effected,  through  the  sheath  after  removal  of  the  telescope,  or  more 
slowly  through  the  faucets,  even  while  the  process  of  catheterization  is 
going  on;  the  separation  of  the  catheters  in  their  grooves  avoids  friction 


FIG.  40. — Buerger  catheterizing  cystoscope:*  1,  concave  sheath;  2,  convex  sheath; 
,?b,  extra  lamps;  3,  observation  or  examining  telescope;  4.  obturator;  5,  catheterizing 
telescope;  6,  clip  to  hold  catheter  against  telescope. 

between  them,  and  a  new  catheter  can  be  inserted  at  any  time  without 
removing  the  telescope;  the  relation  of  the  lamp  to  the  objective  lens 
gives  the  best  illumination  and  prevents  burning  of  the  bladder  wall; 
inasmuch  as  the  catheter-bearing  mechanism  is  separable  from  the 
sheath,  and  is  not  introduced  until  the  bladder  is  cleaned,  the  likelihood 

*  For  children,  Buerger  has  constructed  a  single  catheterizing  cystoscope  of  15  French 
caliber,  and  recommends  a  12  French  observation  cystoscope  of  the  Otis-Nitze  type  for 
observation  cystoscopy. 


68  THE  CYSTOSCOPE  AXD  ITS   USE 

of  carrying  infection  into  the  ureters  is  reduced  to  the  minimum ;  if  the 
lens  becomes  soiled,  the  telescope  may  be  removed  without  disturbing 
the  sheath,  or  a  larger  observation  telescope  may  be  substituted. 

The  typical  sheath  carries  the  lamp  on  the  concave  side  of  the  instru- 
ment (Fig.  40,  No.  1)  and  is  called  the  concave  type  of  sheath,  the 
fenestra  and  lamp  being  on  the  same  side.  An  additional  sheath  is 
provided  (Fig.  40,  Xo.  2),  in  which  the  convex  portion  of  the  beak  en- 
closes the  lamp.  This  allows  of  very  close  approximation  of  instrument 
and  bladder  wall,  and  is  applicable  in  contracted  bladders,  where  dis- 
tention  of  the  bladder  is  impossible,  when  a  very  close  view  is  essential, 
whenever  work  must  be  done  at  close  range,  and  when  the  sphincter 
and  posterior  urethra  are  to  be  examined,  particularly  in  prostatic 
adenoma  (hypertrophy) . 

Composite  or  Universal  Cystoscope. — A  number  of  workers  have  at- 
tempted to  make  the  direct  and  indirect  methods  of  procedure  appli- 
cable in  one  sheath.  For  this  purpose  the  sheath  is  provided  with  two 
fenestrse,  one  on  the  concave  side  of  the  lamp  for  the  indirect  telescope, 
the  other  at  the  convexity  for  the  projection  of  the  objective  of  the 
direct  telescope.  Because  of  the  larger  size  of  the  beak,  the  inadequacy 
of  illumination  for  indirect  vision,  the  weakness  of  the  mechanism  in 
the  region  of  the  beak,  and  many  other  mechanical  disadvantages 
such  instruments  are  not  recommended.  F.  Tilden  Brown  and  Brans- 
ford  Lewis  have  both  devised  instruments  of  this  type. 

Endoscopic  Tubes. — These  are  simple  tubes  of  varying  diameters,  and 
are  called  urethroscopes  when  employed  for  inspection  of  the  urethra. 
They  are  of  two  types,  male  and  female.  Gruenfeld  introduced  these 
in  1881  for  use  in  the  urethra,  and  both  Pawlik  and  Howard  Kelly, 
of  Baltimore,  demonstrated  that,  at  least  in  the  female,  the  ureters 
could  be  catheterized  with  comparative  ease  through  a  mere  tube, 
into  which  light  could  be  reflected  from  a  forehead  mirror  from  a  lamp 
situated  near  the  eye  portion  of  the  tube  or  from  a  small  light  carrier 
inserted  into  the  tube  itself. 

The  Elsner-Braasch  Cystoscope. — This  is  a  modified  endoscope  con- 
sisting of  a  sheath  carrying  a  beak  and  lamp,  an  obturator  and  a  small 
glass  window  to  close  the  eye-end  of  the  tube.  When  used  in  a  water 
medium,  a  direct  view  is  obtained  without  the  intervention  of  any 
lenses,  the  observer  looking  through  the  window  down  the  water-filled 
sheath.  Ureteral  catheters  may  be  passed  through  special  channels, 
no  deflector  being  necessary,  the  technic  being  similar  to  that  employed 
with  the  direct  cystoscopes.  Because  of  the  restricted  field  of  vision 
the  wide  excursions  necessary  to  bring  the  bladder  interior  into  view, 
and  the  difficulty  of  finding  the  ureters,  particularly  in  pathological 
bladders,  the  instrument  will  scarcely  find  general  adoption.  In  the 
hands  of  a  very  few  experts  it  may  answer  in  the  majority  of  cases. 

The  Kelly  Endoscope.— A  simple  tube  (Fig.  41)  provided  with  an 
obturator  and  handle  is  successfully  used  by  many  for  ureteral  cathe- 
terization  in  the  female  and  also  for  inspection  of  the  bladder.  Light 
is  thrown  into  the  bladder  with  a  forehead  mirror.  In  certain  modified 


TOSCOPIC  ACCESSORIES  69 

models  of  this  instrument  a  small  lamp  is  attached  either  to  the  eye-end 
of  the  tube  or  carried  inward  on  a  small  light  carrier.  The  Kelly- 
Pawlik  method  is  not  recommended  for  observation  cy^toscopy.  since 
the  field  obtained  is  too  limited.  In  the  female,  however,  it  has  a 
sphere  of  usefulness  for  purposes  of  ureteral  catheterization. 


FIG.  41 . — Kelly  speculum  or  endoscope, 

The  Luys  Endoscope. — Luys  employs  a  simple  endoscopic  tube  for 
catheterization  of  the  ureters  even  in  the  male,  and  has  modified  the 
instrument  by  the  addition  of  a  small  magnifying  lens  in  front  of  the 
eye-end  of  the  instrument  and  a  small  canal  through  which  the  urine 
can  be  aspirated  and  the  field  kept  dry. 

CYSTOSCOPIC  ACCESSORIES. 

The  Lighting  Apparatus. — The  source  of  electricity  is  preferably  the 
street  current,  but  a  dry  cell,  storage  or  other  battery  may  be  employed. 
The  requisite  amount  of  current  is  obtainable  through  a  controller* 
that  can  be  attached  to  any  universal  lamp  socket.  Current  should  be 
turned  on  gradually  until  the  outlines  of  the  lamp  filament  become 
blurred  and  the  light  becomes  white,  the  instrument  being  tested  and 
the  proper  amount  of  current  determined  before  its  introduction  into 
the  bladder.  Dry-cell  batteries  (single  or  six-cell  pocket  battery  with 
rheostat)  are  often  serviceable,  though  larger  portable  batteries  con- 
taining two  to  six  cells  will  last  longer  and  give  more  satisfaction  in  an 
office  not  equipped  with  electric  light.! 

Sterilization. — After  cleansing  with  green  soap  and  water,  then 
alcohol,  tbe  cystoscope  may  be  sterilized  either  in  pure  carbolic  acid  or 
in  formaldehyde  vapor.  A  carbolic  acid  sterilizer  may  be  improvised 
by  placing  two  large  tubes  or  cylindrical  vessels  in  a  wooden  stand, 
one  containing  carbolic  acid  and  the  other  95  per  cent,  alcohol.  The 
eystoscope  is  plunged  into  carbolic  acid  for  five  minutes,  then  immersed 
in  alcohol,  and  finally  washed  with  sterile  water. 

*  The  Wappler  controller.  Xo.  3,  is  one  of  the  best  instruments  for  this  purpose, 
t  Wappler  Catalogue,  No.  59,  p.  19. 


70  THE  CYSTOSCOPE  AND  ITS   USE 

A  formaldehyde  sterilizer*  in  which  there  is  provision  for  the  develop- 
ment of  formaldehyde  is  even  more  reliable.  Formaldehyde  vapor  is 
developed  by  allowing  a  tablet  of  paraform  to  be  vaporized  over  a  lamp. 
The  instruments  should  be  kept  in  this  vapor  for  several  hours,  pre- 
ferably overnight,  and  must  be  rinsed  off  with  sterile  water  before 
using. 

Cystoscopic  Table.- — A  table  suitable  for  cystoscopic  work  should  per- 
mit the  patient  to  be  comfortably  placed  in  the  following  positions: 
lithotomy  position,  the  modified  lithotomy  position  with  legs  hanging 
down,  Trendelenburg,  and  knee-chest  position,  f 

Anesthesia. — Although  an  anesthetic  may  be  dispensed  with  in  many 
cases,  it  is  a  good  plan  to  employ  novocain  or  alypin  as  a  routine  in 
males,  and  occasionally  even  in  the  female.  A  2  and  4  per  cent,  solution 
of  novocain  and  a  l£-grain  tablet  of  alypin  or  novocain  should  be  at 
hand.  Lubrichondrin  or  K  Y,J  to  which  4  per  cent,  novocain  or  alypin 
has  been  added  (Barringer),  is  a  good  preparation. 

The  following  is  a  useful  method  of  obtaining  local  anesthesia :  After 
cleansing  of  the  foreskin  and  meatus,  the  patient  voids,  and  the  urethra 
is  irrigated  with  a  2  per  cent,  boric  acid  solution.  The  anterior  urethra 
is  then  distended  with  a  2  to  4  per  cent,  novocain  solution  and  closed 
with  a  penis  clamp.  After  five  minutes  have  elapsed,  about  15  c.c.  of 
the  novocain  solution  are  injected  into  the  urethra  in  such  a  manner 
that  the  greater  part  of  this  solution  enters  the  bladder,  the  urethra 
remaining  distended  for  an  additional  five  minutes.  Some  recommend 
the  introduction  of  a  tablet  of  alypin  or  novocain  (1|  gr.)  into  the  pos- 
terior urethra  by  means  of  a  special  tablet  depositor  (Bransford  Lewis), 
or  the  injection  of  a  4  per  cent,  alypin-lubrichondrin  into  the  urethra 
for  five  minutes,  the  instrument  being  then  anointed  with  the  same 
preparation. 

Suppositories  containing  1  grain  of  codein  or  \  grain  of  the  extract  of 
belladonna  with  \  grain  of  the  extract  of  opium  may  be  administered 
an  hour  before  the  examination  in  irritable  patients.  In  rare  instances 
nitrous  oxide  gas  anesthesia  or  epidural  injection  of  10  c.c.  of  a  0.5 
per  cent,  novocain  solution  will  be  necessary. 

Solutions. — Since  cystoscopy  with  telescopic  instruments  necessitates 
the  distention  of  the  bladder  with  a  clear  fluid,  a  warm  2  per  cent,  boric 
acid  solution  must  be  at  hand.  It  is  best  employed  in  an  irrigator,  but 
may  also  be  injected  with  a  5-  to  6-ounce  syringe. 

Indigo-carmin  (0.08)  mixed  and  boiled  in  15  to  20  c.c.  of  sterile 
normal  salt  solution  may  be  injected  into  the  buttocks,  if  selected  as  a 
functional  test;  or  phenolsulphonephthalein§  (vial  of  1  c.c.)  is  intro- 
duced either  into  one  of  the  arm  veins  or  under  the  skin. 

Ureteral  Catheters. — The  French  silk- woven  catheters^  are  the  best. 
They  vary  in  size  and  in  the  shape  of  their  tips  or  collecting  ends.  They 

*  Hospital  Supply  Company,  New  York. 

t  Buerger-Hyman   table  made  by  the   Hospital   Supply   Company,   was  especially 
designed  for  this  work;  or  the  Buerger  combined  cystoscopic  and  radiographic  table. 
J  Van  Horn  &  Sawtell,  New  York. 
§  Hynson  &  Westcott,  Baltimore,  Maryland,     f  Eynard  make  is  recommended. 


CYSTOSCOPIC  ACCESSORIES  71 

may  terminate  in  an  olivary  point  with  one  or  two  lateral  openings,  in 
a  whistle-shaped  tip,  with  lateral  holes,  in  a  single  terminal  opening 
without  any  lateral  holes,  or  with  a  rounded,  closed  end  with  a  lateral 
opening.  The  most  serviceable  are  the  olive-tip  and  the  whistle-tip 
catheters;  the  former  are  preferred  for  routine  work  since  they  more 
easily  surmount  obstruction  in  the  ureter ;  the  latter  have  the  advantage 
of  giving  a  somewhat  more  copious  flow. 

Although  the  No.  6  French  catheter  is  recommended  for  routine 
use,  it  will  be  necessary  occasionally  to  employ  one  of  4  or  5  French 
caliber.  In  pyelography  where  reflux  of  the  injected  argyrol  or  collargol 
must  be  prevented,  or  in  estimating  the  total  output  of  a  kidney,  or  in 
order  to  collect  thick  purulent  secretions,  etc.,  a  larger  catheter  from 
7  to  12  French  may  be  introduced  through  an  operating  cystoscope.* 

Lubricants. — A  lubricant  containing  tragacanth  put  up  in  tubes  has 
given  us  satisfaction.!  Four  per  cent,  novocain  or  4  per  cent,  alypin 
may  be  added  to  aid  local  anesthesia.  Sterile  glycerin  or  liquid  petro- 
latum may  also  be  employed. 

Syringes. — A  complete  outfit  includes  a  1-ounce  syringe  with  rubber 
tip  for  injection  of  novocain  solution;  a  small  5  to  10  c.c.  syringe  for 
washing  the  pelvis  of  the  kidney,  injecting  fluid,  oil,  or  glycerin  into  the 
ureteral  catheters  and  provided  with  a  special  conical  blunt  needle  to  fit 
into  any  ureteral  catheter;  a  20-c.c.  syringe  for  indigo-carmin  injection; 
a  small  hypodermic  syringe  for  injection  of  phenolsulphonephthalein; 
and  a  5-ounce  syringe  for  injecting  fluid  into  the  bladder  when  an  irri- 
gator  is  not  at  hand. 

Other  Accessories. — Other  accessories  are  rubber  tips  or  nipples,  with 
or  without  perforation,  to  occlude  the  catheter  outlets;  clips  to  hold 
catheters  in  their  beds  in  the  telescope;  cystoscope  holder,  especially 
valuable  in  females  to  grasp  the  cystoscope  and  to  hold  two  test-tubes 
for  collecting  specimens. 

Preparation  for  Cystoscopy. — Although  a  complete  armamentarium 
for  the  use  of  the  specialist  includes  a  larger  number  of  instruments,  a 
satisfactory  set  would  include  a  Buerger  observation  and  catheterizing 
cystoscope, J  an  Otis-Xitze  examining  cystoscope, §  a  cysto-urethro- 
scope,^[  an  operating  cystoscope,**  and  a  Kelly  endoscope.ft 

The  cystoscope  selected  for  use,  after  sterilization,  is  laid  out  on  a 
sterile  towel  and  the  lamp  tested.  Preparation  of  a  male  patient 
includes  the  cleansing  of  the  external  parts,  the  irrigation  of  the  urethra 
with  a  2  per  cent,  boric  solution  with  a  hand  syringe  followed  by  the 
application  of  the  local  anesthetic.  After  ten  minutes  have  elapsed 

*  Buerger  or  Brown  or  Bransford  Lewis  instruments. 

t  So-called  "K-Y,"  Van  Horn  &  Sawtell,  New  York. 

j  Manufactured  by  Wappler  Electric  Mfg.  Company,  catalogue  59,  p.  2,  Brown- 
Buerger  combination  cystoscope. 

§  Wappler  Electric  Manufacturing  Company. 

If  Wappler  catalogue  59,  pp.  9,  10  and  11  (Buerger  cysto-urethroscopes) . 

**  Ibid.,  pp.  6  and  7,  Buerger  operating  cystoscope. 

ft  Manufactured  by  all  surgical  instrument  makers  under  the  name  of  Kelly  speculum 
or  Kelly  endoscope. 


72  THE  CYSTOSCOPE  AXD  ITS   USE 

the  patient  may  be  put  in  the  position  for  cystoscopy.  In  the  case  of 
the  female,  after  irrigation  of  the  vagina  and  thorough  cleansing  of  the 
external  parts,  a  tablet  of  novocain  or  alypin  may  be  introduced  into 
the  urethra  with  forceps.  A  slightly  modified  lithotomy  position  will 
be  found  to  answer  in  most  cases,  except  for  the  Kelly  and  Luys 
methods,  which  require  either  the  knee-chest  posture  or  an  exaggerated 
Trendelenburg. 

The  Introduction  of  the  Instrument. — In  the  case  of  the  female  this 
requires  no  special  comment,  but  in  the  male  the  technic  is  as  follows: 
The  operator  standing  in  front  of  the  patient  holds  the  penis  in  the  left 
hand,  puts  it  on  the  stretch,  everts  the  lips  of  the  meatus,  and  is  ready 
to  pass  the  well-lubricated  cystoscope  through  the  urethra.  The  sheath 
with  the  obturator  in  place  is  allowed  to  slip  into  the  urethra  as  far  as 
the  bulb,  by  its  own  weight  whenever  possible,  until  it  meets  the  resist- 
ance of  the  bulbomembranous  junction.  Here  it  is  allowed  to  rest  for 
a  second  or  more.  The  ocular  end  of  the  instrument  is  then  depressed 
until  a  sensation  of  penetration  begins  to  make  itself  manifest.  A  slight 
rotation  of  the  beak  from  one  side  to  the  other  may  facilitate  in  this 
maneuver,  and  a  finger  of  the  left  hand  (which  has  now  released  the 
penis)  may  aid  by  pressing  the  beak  of  the  cystoscope  upward  against 
the  pubic  arch.  The  instrument  will  then  suddenly  plunge  through 
the  posterior  urethra  and  into  the  bladder,  while  the  right  hand  con- 
tinuously depresses  the  ocular  end.  The  obturator  is  then  removed, 
the  urine  collected  in  a  sterile  vessel,  and  the  bladder  is  irrigated  with 
a  2  per  cent,  boric  solution  from  an  irrigator  until  the  return  flow  is 
perfectly  clear.  Either  the  observation  or  the  catheterizing  telescope 
is  now  inserted,  locked  in  place,  and  the  boric  acid  allowed  to  flow  into 
the  instrument  through  one  of  the  lateral  faucets  until  150  to  200  c.c. 
have  entered. 

Technic  of  Observation  Cystoscopy. — Four  motions  of  the  cysto- 
scope must  be  mastered :  motions  of  translation,  rotation,  a  pendulum 
or  rocking  motion,  and  a  motion  of  circumduction. 

By  the  motion  of  translation  we  mean  an  inward  and  outward  move- 
ment of  the  instrument  (introduction  and  withdrawal).  In  Fig.  42 
the  positions  A ,  B  and  C  bring  into  view  the  greater  portion  of  the  an- 
terosuperior  wall,  vertex  and  posterosuperior  region.  When  associated 
with  rotation  around  the  long  axis  of  the  shaft,  the  lateral  walls  and 
floor  also  are  visualized  (Fig.  34).  A  motion  of  translation  alone,  when 
the  beak  is  turned  down,  gives  a  survey  of  a  band  of  the  floor  of  the 
bladder,  whose  width  depends  upon  the  distance  of  the  objective  lens 
from  the  floor,  it  being  remembered  that  the  nearer  the  objective,  the 
smaller  the  field.  Complete  rotation  affords  a  view  of  an  annular  band 
extending  around  the  whole  bladder.  Therefore  the  two  motions  of 
rotation  and  translation  demonstrate  practically  the  whole  of  the 
bladder  except  a  small  area  of  the  posterior  wall  and  the  immediate 
neighborhood  of  the  sphincter. 

The  combined  motions  of  introduction,  withdrawal,  and  rotation  do 
not  suffice,  since  the  illumination  is  scarcely  adequate  at  all  distances, 


CYSTOSCOPIC  ACCESSORIES 


73 


and  since  details  will  not  be  sufficiently  magnified  until  the  objective 
is  brought  nearer  to  the  bladder  wall. 

Therefore  the  rocking  or  pendulum  motion  is  useful.  By  this  we 
mean  the  elevation  and  depression  or  side-to-side  movement  of  the 
ocular  with  consequent  conjugate  motions  of  the  beak.  These  are 
appropriate  to  exhibit  the  posterior  wall  (Fig.  43),  and  the  juxta- 


FIG.  42. — Inspection  of  (A)  anterosuperior,  ((7)  posterosuperior,  and  (B)  vertex, 
by  motion  of  translation;  in  a  similar  manner  the  floor  of  the  bladder  (Z>)  is  brought 
into  view. 

sphincteric  portions  of  the  anterior  wall ;  for  the  purpose  of  magnifying 
objects,  and  for  special  conditions,  as  in  cystocele,  diverticula,  adenoma 
of  the  prostate,  etc. 


FIG.  43. — Rocking  or  pendulum  motion  to  demonstrate  the  posterior  wall. 

Motions  of  circumduction  combine  the  rocking  motion  with  rotation 
and  offer  the  possibility  of  a  more  comprehensive  view  of  larger  objects, 
such  as  stones  or  tumors. 

The  Routine  of  Inspection. — The  following  is  a  useful  scheme : 
First:  Obtain  a  superficial  view  of  the  superior  wall  with  the  beak 
turned  up,  introducing  and  withdrawing  until  the  air-bubble  comes  into 


74 


THE  CYSTOSCOPE  AND  ITS   USE 


view  (Fig.  44) .  The  air-bubble  occupies  the  highest  point  of  the  bladder, 
being  air  introduced  into  the  bladder  upon  insertion  of  the  sheath. 
Do  not  tarry  in  this  examination,  since  the  inspection  of  the  floor  of  the 
bladder  is  most  important  and  should  be  executed  first. 

Second:  Examine  the  floor  (including  trigone  and  ureteric  orifices) 
after  having  rotated  the  instrument  so  that  the  beak  looks  down. 
(Fig.  42,  D.) 


FIG.  44. — Air-bubble  seen  with  the  beak  turned  upward  when  vertex  is  inspected. 

Third:  Finding  of  the  ureters.  Carry  the  cystoscope  well  into  the 
bladder  (Fig.  45)  and  the  field  becomes  dark,  for  the  lamp  has  impinged 
against  the  posterior  bladder  wall,  leaving  the  greater  part  of  the  field 
dark  (Fig.  46) ;  withdraw  slightly  and  the  retrotrigonal  region  appears. 
If  the  illumination  is  imperfect,  you  are  probably  too  far  away  from  the 


FIG.     46. — View     obtained 
with  the   cystoscope  as  seen 
FIG.  45. — Finding  of  the  ureters;  first  position.  in    Fig.  45.     Upper    part  of 

field  illuminated,  lower  por- 
tion dark.  If  cystoscope  is 
pushed  still  farther  in,  the 
whole  field  may  become  dark. 

floor,  and  the  ocular  must  be  raised.  Continue  the  recessive  motion 
(withdrawal)  until  the  interureteric  bar  or  ridge,  a  fold  running  trans- 
versely between  the  ureters,  comes  into  view  (Figs.  47  and  48).  This 
is  distinguished  by  its  marked  vascularity,  darker  color,  and  prominence 
in  the  male,  although  in  the  female  the  markings  may  be  less  distinc- 
tive. Even  here,  however,  the  change  in  the  color  of  the  mucous  mem- 
brane, fascicles  of  prominent  vessels,  running  sagittally,  will  indicate 


CYSTOSCOPIC  ACCESSORIES 


75 


its  presence.    Allow  the  bar  to  occupy  the  centre  of  the  field  ang!  rotate 
about  20  degrees  to  either  side  and  the  ureters  will  come  into  view 


FIG.  47. — Finding  of  ureters.  Second  position. 
The  interureteric  bar  o'ccupies  the  middle  of  the 
field. 


FIG.  48.  — View  obtained 
with  the  cystoscope  as  in  Fig. 
47 ;  the  interureteric  bar  runs 
across  the  field;  above,  the 
retro  trigonal  region;  below, 
the  more  vascular  area  of  the 
trigone.  The  ureteral  orifices 
lie  outside  of  the  field. 


(Fig.  49) .  Examine  the  ureters  carefully,  both  with  the  instrument  in 
the  position  of  lateral  rotation  and  also  with  the  shaft  carried  into  the 
line  of  the  course  of  the  ureter,  a 
position  which  is  obtained  by  bring- 
ing the  beak  toward  the  opposite  side 
of  the  patient.  By  raising  the  ocular 
the  details  of  the  ureteric  orifices  will 
be  brought  distinctly  into  the  field. 
Note  the  intermittent  vermicular 
contractions  of  the  ureteral  orifices 
and  the  character  of  the  efflux  or 
urinary  jet. 

Fourth:  Study  the  trigone  itself. 

Fifth:  Proceed  to  the  inspection 
of  the  superior  wall  by  turning  the 
beak  upward. 

Sixth:  View  the  lateral  walls  by 
combining  the  motion  of  translation 
with  rotation,  and  with  the  cradle 
motion  so  as  to  bring  the  beak  nearer 
to  the  wall. 

Seventh:  Examine  the  posterior 
wall  with  the  beak  down  or  up  by  a 
rocking  motion  (Fig.  43) . 

Eighth:  Inspect  the  sphincter  by 
rotation  after  having  drawn  the 

objective  into  the  urethrosphincteric  margin,  so  that  the  prism  lies 
partly  within  the  urethra,  partly  within  the  bladder. 


FIG.  49. — Finding  the  ureters.  Third 
position.  /,  cystoscope  in  the  midline 
looking  at  the  interureteric  bar;  //, 
cystoscope  turned  to  the  patient's  right 
to  see  the  right  ureter;  III,  to  the  left, 
to  see  the  left  ureter. 


76 


THE  CYSTOSCOPE  AND  ITS   USE 


Ninth:  Remove  the  instrument  with  the  light  turned  off,  the  tele- 
scope removed,  and  with  the  obturator  reinserted. 

Elementary  Principles  of  Observation  Cystoscopy. — For  a  thorough 
comprehension  of  the  field  of  view  (outer  field)  of  the  indirect  cysto- 
scope,  certain  elementary  physical  principles  must  be  known:  (1) 
we  must  study  the  relation  of  the  inner  field  to  the  position  of  the 
cystoscope;  (2)  the  movements  of  this  field  induced  by  the  motions  of 
the  instrument;  (3)  the  problem  of  magnification;  (4)  the  observation 
of  the  internal  sphincteric  region;  and  (5)  the  question  of  illumination. 


FIG.  50. — Viewing  the  floor  of  the  bladder,  far  point  (north)  occupies  the  upper  portion 
of  the  field,  near  point  (tail  of  the  arrow)  the  lower  part  of  the  field. 

Relation  of  Field  and  Cystoscope. — It  is  necessary  to  remember  that 
the  eye  of  the  observer  is  transferred  to  the  objective  of  the  cystoscope 
and  looks  in  a  direction  perpendicular  to  the  shaft  of  the  instrument. 
With  the  objective  looking  down  upon  the  floor  of  the  bladder  the  field 
is  that  of  a  swimmer  headed  in  the  same  direction  as  the  beak.  The 
view  obtained  by  the  cystoscope  as  it  is  pushed  inward  is  comparable 
to  that  of  such  a  swimmer  (Fig.  50) . 

When  the  anterior  and  superior  walls  are  inspected  the  view  is  that 
of  one  swimming  on  his  back  and  looking  upward  at  the  vertex  of  the 
bladder  (Fig.  51). 

When  the  right  wall  is  examined,  the  swimmer  is  treading  water  and 
looking  to  the  patient's  right,  so  that  a  "far"*  point  will  be  on  the 
examiner's  right ;  conversely,  for  the  left  wall,  the  swimmer  looks  to  the 
left  and  the  far  points  will  be  on  his  left. 

*  Far  points  in  the  anteroposterior  direction  are  away  from  the  cystoscopist,  hence 
nearer  the  posterior  wall. 


CYSTOSCOPIC  ACCESSORIES  77 

Induced  Movements  of  the  Field. — One  of  the  most  disturbing  phe- 
nomena is  the  apparent  movement  of  the  interior  of  the  bladder  con- 
sequent upon  motion  of  the  cystoscope.  The  up-and-down  motions 
that  attend  movements  of  translati6n  are  easily  comprehended  by 
keeping  the  positions  of  the  swimmer  in  mind.  But  when  the  cysto- 
scope is  rotated  on  its  long  axis,  or  when  a  rocking  motion  is  carried  out, 
the  changes  in  the  field  are  somewhat  more  confusing. 

On  rotating  the  cystoscope  with  the  beak  down,  toward  the  patient's 
right  (clockwise),  the  field  will  seem  to  travel  in  a  similar  direction. 
Thus,  when  the  right  ureter  is  being  viewed  the  interureteric  bar  and 
right  border  of  the  trigone  w^ill  be  seen  to  rotate  about  the  ureteric 
orifices  as  a  centre,  although  this  centre  will  travel  toward  the  obser- 
ver's right.* 


FIG.  51. — Inversion  of  the  field  when  the  beak  is  turned  upward;  the  near  point  occupies 
the  upper  portion  of  the  field. 

With  the  cystoscope  looking  at  the  floor  of  the  bladder  (Fig.  52), 
depression  of  the  ocular  (cradle  movement  in  a  sagittal  plane)  imparts 
a  downward  motion  to  the  object.  This  is  tantamount  to  advancing 
the  instrument,  except  that  the  details  of  the  field  will  become  smaller, 
and  the  illumination  will  become  poorer  (Figs.  53,  54  and  55). 

Magnification. — To  produce  enlargement  the  ocular  must  be  moved 
so  as  to  approximate  objective  and  outer  field.  The  ocular  must  go 
upward  in  viewing  the  floor,  downward  for  the  roof.  Such  rocking 
motions  tend  also  to  throw  objects  out  of  the  field,  depression  of  the 

*  The  opposite  motion  will  be  conferred  upon  the  field  by  rotation  of  the  instrument 
to  the  left, 


78 


THE  CYSTOSCOPE  AND  ITS   USE 


beak  toward  the  floor  having  the  effect  of  withdrawing  the  instrument. 
Hence,  to  compensate,  slight  intrusion  of  the  cystoscope  is  necessary. 
The  Problem  of  the  Sphincter. — Here,  three  disturbing  factors  are 
encountered;  the  proximity  of  lens  and  field,  the  great  enlargement, 
and  the  difficulty  of  obtaining  adequate  illumination.  The  concave 


FIG.  52. — Induced  movement  of  the  field  by  depressing  the  ocular  when  a  stone  on  the 
floor  of  the  bladder  is  being  inspected. 

sheath  is  inferior  to  the  convex  here,  since  the  lamp  of  the  latter  can 
be  brought  into  better  relation  with  the  juxtasphincteric  and  urethro- 
sphincteric  regions.  The  cysto-urethroscope  gives  the  best  picture  here. 
The  roof  and  sides  of  the  internal  sphincter  normally  present  a 
concave  line,  that  portion  of  the  bladder  occupying  the  concavity  being 
darker  because  the  illumination  is  inadequate  (Fig.  56).  The  floor  is 


FIG.  53. — Stone  is  in  the 
centre  of  the  field. 


FIG.  64. — Stone  has  moved 
downward  and  is  smaller. 


FIG.  55. — Stone  is  almost 
out  of  the  field  and  is  still 
smaller. 


somewhat  convex. '  These  concave  and  convex  lines  represent  the 
margin  of  the  sphincter  in  the  direction  of  an  approximately  horizontal 
plane.  Any  abnormality  in  this  plane,  such  as  intravesical  intrusion 
due  to  prostatic  adenoma  (hypertrophy)  will  alter  the  concave  to  a 
convex  line.  In  the  vertical  plane  outgrowths  are  difficult  to  estimate, 
since  they  will  have  no  other  effect  than  one  of  magnification, 


URETER AL  CATHETER1ZATION  79 

Light.— The  quality,  intensity,  and  position  of  the  light  will  vary 
according  to  type  of  lamp,  three  forms  being  in  use:  with  the  lamp  in 
the  concave  sheath ,  in  the  convex  sheath,  and  in  the  cysto-urethroscope. 
The  illumination  varies  also  with  the  distance  of  the  lamp  from  the 
field;  and  finally  it  will  depend  upon  the  relation  of  the  lamp  to  the 
mucous  membrane,  being  modified  by  the  presence  of  tumors,  foreign 
bodies  (calculi,  etc.),  and  the  displacements  produced  by  extravesical 
causes. 


ROOF 


FIG.  56. — Diagrammatic  drawing  showing  the  view  obtained  at  the  sphincter,  the  roof, 
the  floor,  the  right  and  left  side  being  shown. 

Up  to  a  certain  point  approximation  enhances  the  intensity  of  the 
light,  but  when  the  lamp  comes  too  close  to  the  mucous  membrane, 
illumination  diminishes,  particularly  when  the  lamp  is  in  contact  with 
the  mucous  membrane.  Then  transillumination  and  shadow  formation 
occur. 

When  the  cystoscope  is  too  far  back  in  the  bladder  (Fig.  45)  the 
lamp  becomes  covered  by  mucous  membrane  and  the  light  is  shut  off. 
A  tumor  may  throw  a  shadow  by  obscuring  the  light,  so  also  a  calculus, 
as  well  as  an  enlarged  uterus,  a  myoma,  or  a  tumor  outside  of  the  blad- 
der. Prostatic  adenoma  ("hypertrophy")  leads  to  the  formation  of  a 
retroprostatic  pouch  and  prevents  the  approximation  of  the  beak  and 
mucous  membrane  so  that  light  is  diminished.  So  also  do  prolapse  of 
the  uterus  and  cystocele  interfere  with  illumination.  Some  of  these 
conditions  can  be  overcome  by  compensating  movements  of  the 
instrument  by  pressure  over  the  abdominal  wall  or  by  manipulation 
of  the  vaginal  wall  in  the  case  of  cystocele. 

URETERAL  CATHETERIZATION. 

Technic  with  the  Indirect  Cystoscope. — The  technic  with  the 
Buerger  cystoscope  will  be  described,  since  this  is  commonly  employed.  * 
In  the  majority  of  cases,  synchronous  ureteral  catheterization  is  ad- 
vised, since  the  collection  of  urine  simultaneously  from  both  kidneys  is 

*  In  the  United  States. 


80 


THE  CYSTOSCOPE  AND  ITS   USE 


invaluable  in  determining  the  relative  function  of  the  two  organs, 
aided  with  the  use  of  such  tests  as  the  phenolsulphonephthalein  and 
indigo-carmin  and  the  chemical  microscopic  and  cultural  examination 
of  the  separated  specimens. 

The  catheterizing  telescope  is  armed  with  two  Xo.  6  French  ureteral 
catheters;  the  sheath,  observation  telescope,  and  obturator  having  been 


FIG.  57. — Normal  ureteral  catheterization.      First  move. 

position. 


Cystoscope  in  normal 


also  prepared.    After  observation  cystoscopy  has  been  completed,  we 
proceed  to  the  catheterization  of  the  ureters  as  follows: 

1 .  The  ureteral  opening  is  found  and  the  ocular  end  of  the  cysto- 
scope  is  brought  slightly  to  the  opposite  side  of  the  patient.  By  raising 
the  shaft  the  ureteral  slit  is  made  to  occupy  a  point  just  above  the 


FIG.  58. — Cystoscopic  view  in  first  move:  the  ureter  slightly  above  the  centre  of  the 

field. 

centre  of  the  field.  This  position  must  be  rigidly  maintained  during  the 
next  two  steps.  The  ureter  orifice  should  be  about  normal  in  size,  or 
but  slightly  enlarged,  which  can  be  expected  at  a  distance  of  about  three 
quarters  to  one  inch  (Figs.  55  and  58). 

2.  After  the  deflector  has  been  slightly  raised  (just  sufficient  to 
prevent  the  catheter  from  hugging  the  lens)  the  catheter  is  pushed  for- 


URETERAL  CATHETERIZATION 


81 


ward  almost  1  cm.  beyond  the  limit  of  the  field.    Now  the  catheter 
appears  enlarged,  for  it  lies  close  to  the  prism  (Figs.  59,  60  and  61). 

3.  The  deviation  is  gradually  increased  by  raising  the  deflector,  the 
movement  of  the  catheter  in  the  field  being  observed  during  the  pro- 


FIG.  59. — Normal  ureteral  catheterization.    Second  move. 

beyond  the  field. 


The  tip  of  the  catheter  lies 


cedure.  The  tip  of  the  catheter  now  comes  into  view,  first  appearing 
at  the  top  of  the  field  and  gradually  traveling  downward,  its  size  dimin- 
ishing at  the  same  time.  When  its  tip  is  a  short  distance  below  the 
ureter,  it  is  usually  in  the  proper  position;  in  reality  it  then  lies  in  front 


FIG.  60. — Cystoscopic  view.  The 
catheter  is  being  pushed  across  the 
field. 


FIG.  61. — Cystoscopic  view:  the 
catheter  lies  beyond  the  field;  view 
seen  in  Fig.  59. 


<  nearer  the  neck  of  the  bladder),  below  and  slightly  to  the  inner  side  of 
the  ureteral  mouth  (Figs.  62  and  63). 

4.  By  now  raising  the  shaft  of  the  instrument,  and  at  the  same  time 
passing  it  farther  into  the  bladder,  the  tip  of  the  catheter  is  made  to 
M  u    i — 6 


82 


THE  CYSTOSCOPE  AND  ITS   USE 


enter  the  mouth  of  the  ureter.  Therefore  the  cystoscope  and  catheter 
as  a  whole  travel  toward  the  opening  and  not  the  catheter  alone  (Figs. 
64  and  65) .  In  the  picture  we  see  the  ureter  descend  to  meet  the  cathe- 


FIG.    63.  —  Cystoscopic 
view.      The    catheter    tip 
lies  just  below  the  ureteral 
FIG.  62. — Normal  ureteral  catheterization.     Third  move,      opening;  view  seen  in  Fig. 
Catheter  has  received  its  full  inclination.  62. 

ter  at  about  the  middle  of  the  field.  When  the  catheter  has  engaged 
the  ureteral  opening,  it  is  pushed  a  short  distance  forward,  the  deflector 
is  depressed  somewhat,  and,  by  still  further  raising  the  ocular,  the 


FIG.  64. — Normal  ureteral  catheteri- 
zation. Fourth  move.  The  tip  of  the 
catheter  is  made  to  enter  the  ureter. 


FIG.  66.  —  Cystoscopic  view. 
Catheter  has  entered;  view  seen  in 
Fig.  64.* 


introduction  of  the  catheter  becomes  easy.    The  lid  (deflector)  is  now 
turned  upward,  the  other  ureter  sought,  and  the  method  repeated. 

Although  the  above  may  be  considered  as  a  "normal"  method,  cer- 
tain variations  in  technic  will  be  required  in  difficult  or  anomalous  cases. 

*  Note  that  through  an  error  the  ureteral  orifice  has  been  drawn  too  high  in  the  field, 
since  it  must  occupy  a  lower  position  than  in  Fig.  57  after  the  instrument  has  been 
pushed  inward.  Cf.  with  Figs.  51,  52,  53  and  54. 


83 

Thus  we  may  find  it  advantageous  to  change  the  amount  of  deflection 
or  to  retain  the  maximum  deviation  while  pushing  the  catheter  along 
the  ureteral  canal.  If  we  see  that  the  bladder  wall  is  being  raised  con- 
siderably by  the  entering  catheter,  we  know  that  the  anterior  wall  of 
the  ureter  is  being  lifted  up  by  the  catheter.  This  occurs  especially 
when  stiff  catheters  are  used  and  when  the  deflector  has  been  turned 
down  too  far,  for  in  both  instances  the  catheter  has  a  tendency  to  seek 
a  higher  level,  one  approaching  the  plane  of  the  shaft  of  the  instrument. 
To  overcome  this,  three  maneuvers  are  permissible,  either  raising  the 
ocular  so  as  to  bring  the  catheter  more  nearly  in  the  direction  of  the 
uretheral  canal  or  increasing  the  deflection,  or  a  combination  of  both. 
If  carefully  carried  out,  this  procedure  is  far  superior  to  that  by 
which  the  catheter  is  "aimed"  at  the  opening  and  pushed  out  to  meet 
it.  It  affords  a  more  certain  way  of  hitting  the  mark,  avoiding  scraping 
of  the  bottom  of  the  bladder,  and  is  easy  of  execution.  * 


FIG.  66. — Catheterization  with  the  direct  cystoscope. 

Technic  with  the  Direct  Cystoscope. — In  our  experience  the  direct 
method  of  catheterization  is  far  inferior  to  the  indirect.  The  direct 
cystoscope  will  practically  never  be  found  necessary  for  ureteral 
catheterization. 

After  introduction  of  the  instrument,  the  obturator  is  removed  and 
the  bladder  irrigated.  The  telescope  armed  with  two  catheters  is  then 
introduced  and  boric  acid  solution  allowed  to  enter.  The  trigone  is 
then  inspected,  it  being  remembered  that  the  instrument  looks  directly 
forward  and  that  the  intravesical  portion  of  the  instrument  necessarily 
comes  into  contact  with  the  trigone.  The  latter,  therefore,  appears 
considerably  enlarged  and  is  distorted  by  virtue  of  the  fact  that  the 
plane  of  the  field  lies  in  the  axis  of  the  instrument  (Figs.  35  to  38). 
When  the  ureter  is  recognized,  the  ocular  end  of  the  instrument  is 
raised  somewhat  and  the  catheter  introduced  into  the  direction  of  the 

*  For  those  who  catheterize  at  close  range,  particularly  when  the  convex  sheath  is 
used,  the  method  described  need  not  be  followed. 


84 


THE  CYSTOSCOPE  AND  ITS   USE 


canal  (Fig.  66).  The  instrument  is  then  turned  to  the  opposite  side, 
an  attempt  being  made  to  follow  the  interureteric  bar,  and  the  other 
ureter  recognized  and  catheter ized. 

Technic  with  the  Elsner-Braasch  Cystoscope  (or  Endoscope).* — In  the 
hands  of  a  few  experts  this  method  still  finds  application,  but  is  not 
recommended  for  the  average  cystoscopist  because  the  view  is  too 
limited;  thorough  inspection  of  the  bladder  is  impossible;  observation 
cystoscopy  necessitates  wide  excursion  of  the  ocular  end  of  the  instru- 


Retro  pubic  (5) 


Vertex 


Right  cornu  (3) 
Sacral  ar'ea  (?) 


Base  0) 


FIG.  67. — The  position  of  the  Kelly  endoscope  in  viewing  the  bladder. 

and   Burnam.) 


(After  Kelly 


ment ;  the  procedure  is  much,  more  painful  and  disagreeable  than  the 
indirect  method;  in  difficult  cases  the  finding  of  the  ureters  takes  a 
great  deal  more  time  and  is  not  as  certain  as  with  the  indirect  method; 
the  acquisition  of  the  requisite  technic  is  painstaking  and  success  with 
the  method  is  relegated  to  a  very  few. 

As  for  the  technic,  the  instrument  is  introduced  with  the  obturator 
removed,  the  bladder  irrigated,  and  the  ocular  end  is  closed  with  a 
glass  window.  Through  an  irrigating  cock  a  continuous  flow  of  boric 
acid  solution  bathes  the  telescopic  tube  and  enters  the  bladder.  The 

*  For  those  who  occasionally  use  this  method,  the  Buerger  universal  cysto-urethro- 
scope  will  be  found  just  as  serviceable. 


OPERATIVE  CYSTOSCOPY  85 

operator  looks  through  the  glass  window,  inspecting  the  trigone,  and  by 
a  lateral  motion  brings  the  ureteric  orifice  into  view.  The  catheter  is 
then  put  into  the  corresponding  catheter  canal  and  introduced  into  the 
orifice  under  the  guidance  of  the  eye. 

With  the  Kelly-Pawlik  Endoscope. — A  method  for  direct  examination 
of  the  bladder  first  adopted  by  Kelly  and  Pawlik  was  described  by 
H.  A.  Kelly  as  the  rerocystoscopic  method9  (Fig.  67).  In  this  method, 
distention  of  the  bladder  with  air  is  induced  by  posture.  A  simple 
speculum  or  urethroscopic  tube  is  introduced  and  located  by  with- 
drawing the  speculum  until  the  internal  urethral  orifice  is  seen.  It  is 
then  carried  in  a  short  distance  and  pointed  from  20°  to  30°  to  one 
or  the  other  side,  the  base  of  the  bladder  being  viewed.  With  the 
orifice  in  view  a  ureteral  catheter  provided  with  a  stylet  is  held  in  the 
right  hand  for  catheterization  of  the  left  ureter,  in  the  left  hand  for 
entering  into  the  right  ureter.  The  stylet  is  then  removed.  If  we  wish 
to  catheterize  both  ureters,  the  speculum  is  withdrawn,  reinserted,  and 
the  same  maneuvers  carried  out  for  catheterization  of  the  other  ureter. 

Luys's  Method. — Luys  recommends  his  modified  endoscopeor  urethro- 
scope  for  catheterization  of  the  ureter  of  the  male,  employing  an 
exaggerated  Trendelenburg  posture.  The  bladder  is  kept  dry  by  con- 
tinuous suction  through  a  special  canal  in  the  endoscope.  This  method 
will  be  found  too  difficult  and  uncertain  for  anyone  but  the  expert. 

OPERATIVE  CYSTOSCOPY. 

In  this  we  include  all  those  special  diagnostic  and  therapeutic  man- 
ipulations that  can  be  carried  out  through  a  catheterizing  cystoscope 
or  through  an  operative  cystoscope.  The  Buerger  and  Lewis  operating 
cystoscopes  are  the  simplest  and  used  most  widely  in  the  United  States. 
The  Nitze  and  Kuttner  cystoscopes  are  employed  on  the  Continent. 


FIG.  68. — Buerger  operating  cystoscope  with  forceps  of  the  recessive  type  in  place. 

The  Buerger  Operating  Cystoscope. — The  instrument  resembles  the 
catheterizing  cystoscope,  but  its  sheath  is  elliptical  and  its  telescope 
provided  with  but  a  single  outlet  (Fig.  68).  Concave  and  convex 
sheaths  are  provided  and  telescopes  for  giving  either  a  right-angled 


8G 


THE  CYSTOSCOPE  AND  ITS  USE 


view,  an  obliquely  forward  view,  or  a  slightly  retrograde  view,  depend- 
ing upon  the  region  to  be  attacked.  The  right-angled  telescope  will 
suffice  for  almost  all  cases. 

The  Buerger  Combination  Operating  Cystoscope. — This  instrument  at 
first  glance  indistinguishable  from  the  others,  offers  the  possibility  of 
introducing  examining,  catheterizing  and  operating  telescopes  into 
the  same  specially  designed  sheath.  As  far  as  the  requirements  of  ob- 
servation and  operating  cystoscopy  are  concerned,  it  is  identical  with 
the  catheterizing  cystoscope.  For  operating  purposes  it  is  usually 
adequate,  although  it  carries  slightly  smaller  operating  devices. 


FIG.  69. — Working  ends,  operating  forceps  and  snare. 

The  Operating  Instruments. — Two  varieties  are  available,  the  recessive* 
and  non-recessive  or  scissors  type.  In  the  first  the  general  assembly 
includes  a  shank  carrying  the  special  working  ends  or  jaws  (Fig.  69), 
a  flexible  spiral  cannula  and  a  handle.  The  distal  extremity  of  the 
cannula  is  reinforced,  serving  for  the  closure  of  the  jaws  of  the  instru- 
ment. By  means  of  a  universal  scissors  type  of  handle  the  jaws  are 
drawn  into  the  cannula  and  thereby  made  to  close  (Fig.  70).  In  the 
second  type  of  operating  instrument  the  closure  of  the  jaws  is  brought 
about  by  a  scisssors  mechanism  which  obviates  recession  of  the  jaws  as 
they  shut  (Fig.  71).  Grasping,  cutting,  biting  forceps  and  scissors  for 
cutting  the  ureteral  orifices  are  provided. 

A  very  useful  and  simple  instrument  is  a  snare,  which  comprises  a 
spiral  cannula  whose  distal  end  is  capped  with  a  solid  metal  knob  con- 

*  This  type  has  been  found  less  generally  useful  than  the  scissors  type,  the  latter  being 
recommended. 


OPERATIVE  CYSTOSCOPY 


87 


taining  two  perforations  for  the  emergence  of  the  wire  loop  and  whose 
proximal  end  is  fitted  with  a  catheter  channel  which  may  be  closed  by 
a  rubber  tip. 


FIG.  70. — Operating  forceps  in  telescope. 

Besides,  bougies  for  dilatation  of  the  ureter  a  special  bougie  through 
which  the  d'Arsonval  current  may  be  applied  will  be  found  useful. 
A  No.  9  French  silk  ureteral  catheter  serves  to  insulate  a  wire  conductor, 
the  proximal  end  of  which  has  a  coupling  for  attachment  to  the  high- 


FIG.  71. — Scissors  type  of  operating  forceps. 

frequency  machine,  the  distal  end  being  provided  with  a  screw  thread. 
To  the  latter,  metal  olives  of  various  sizes  are  attached  in  sizes  from 
6  to  16  French. 


88  THE  CYSTOSCOPE  AXD  ITS   USE 

The  Technic  of  Operative  Cystoscopy. — In  the  Buerger  instrument 
it  is  possible  to  employ  operative  instruments  of  much  greater  size 
than  the  catheter  outlet  would  seem  to  allow  by  a  retrograde  insertion 
of  the  working  devices.  All  of  the  larger  instruments  must  be  intro- 
duced somewhat  in  advance  of  the  telescope  so  that  they  may  pass 
through  the  telescope  alone,  emerging  through  the  fenestra  before  the 
telescope  is  locked  home. 

1.  Technic  with  the  Recessive  Type  of  Instrument. — The  operating 
telescope  is  prepared  as  follows :     The  cannula  provided  with  a  rubber 
nipple  is  introduced  into  the  telescope  through  the  catheter  outlet  until 
its  extremity  lies  about  1  cm.  beyond  the  lens  prism.    A  suitable  work- 
ing end  with  its  shank  is  now  inserted  in  reverse  fashion  and  the  handle 
securely  attached. 

After  introduction  of  the  sheath  and  thorough  inspection  with  an 
observation  telescope,  fitted  to  the  operating  sheath,  the  operating 
telescope  armed  with  the  instrument  selected  is  introduced  as  follows : 
The  working  end  with  jaws  closed  enters  in  advance,  and,  if  it  is  some- 
what too  large  to  escape  at  the  fenestra  in  all  possible  positions,  may  be 
made  to  emerge  by  slight  motions  of  rotation  or  with  the  aid  of  slight 
deflection  of  the  lid.  With  the  bladder  filled,  the  lesion  or  foreign 
body  is  located.  The  cannula  is  pushed  inward  for  the  requisite  dis- 
tance, the  jaws  are  opened,  and  by  a  combination  of  movement  of  the 
cystoscope  and  deflector  the  part  to  be  attacked  is  readily  seized.  To 
overcome  recession  of  the  jaws  the  cystoscope  or  cannula  must  be 
pushed  inward  slightly  as  the  jaws  are  made  to  close.  Small  bodies, 
tissue,  and  tumors  are  easily  extracted  through  the  sheath,  the  tele- 
scope and  operating  device  being  removed  together.  In  extracting 
larger  bodies,  such  as  a  ureteral  calculus  or  foreign  bodies,  the  cysto- 
scope is  withdrawn  first,  the  forceps  following. 

If  it  is  desired  to  replace  the  particular  operating  device  just  used 
with  another,  the  telescope  is  withdrawn,  the  jaw  with  its  shank 
removed  and  another  inserted,  the  cannula  and  handle  remaining 
undisturbed 

2.  Technic  with  the  Scissors  Type. — After  being  provided  with  a  suit- 
able tip  or  nipple  the  operating  instrument  (forceps  or  scissors)  is 
adapted  to  the  sheath  by  being  passed  through  the  catheter  outlet. 
Larger  jawed  instruments  must  be  inserted  in  the  manner  described  as 
suitable  for  the  recessive  instruments.     The  technic  is  the  same  as 
recounted  above,  except  that  it  is  unnecessary  to  move  cystoscope  or 
cannula  while  the  jaws  close.    It  is  best  to  open  the  jaws  before  deflec- 
tion, since  bending  of  the  cannula  interferes  with  easy  working  of  the 
instrument.     Whenever  small  devices  are  needed  the  scissors  type  is 
recommended;  when  larger  forceps  for  removal  of  foreign  bodies,  as 
ureteral  calculi,  are  required,  the  recessive  type  is  preferable. 

Methods  in  Operative  Cystoscopy. — The  Diagnosis  of  Ureteral  Cal- 
culi by  Means  of  Wax-tipped  Catheters. — This  method  of  detecting  a 
calculus  in  the  ureter  through  scratch  marks  left  upon  the  surface 
of  a  wax-tipped  catheter  was  first  suggested  by  Kelly,  of  Balti- 
more. In  females  there  will  be  no  danger  of  producing  adventi- 
tious scratch  marks,  if  the  Kelly  endoscope  is  used.  In  the  male, 


89 

when  the  direct  cystoscope  is  employed,  the  following  special  technic 
must  be  observed:  Either  the  catheterizing  cystoscope  or  the  opera- 
ting cystoscope  is  selected,  preferably  the  latter.  A  No.  5  French 
olive-tipped  ureteral  catheter*  is  prepared  by  dipping  the  tip  into  a 
mixture  of  equal  parts  of  paraffin  and  beeswax.  On  withdrawal  from 
the  mixture  a  small  fusiform  mass  of  hardened  wax  remains.  The  fol- 
lowing technicf  is  to  be  followed  in  the  male.  After  irrigation  of  the 
bladder  with  a  catheter  a  sterile  wax-tipped  catheter  is  introduced 
through  the  urethra  and  made  to  coil  up  in  the  bladder.  The  sheath  of 
the  cystoscope  is  then  threaded  over  it  and  then  the  catheterizing  tele- 
scope is  inserted,  the  butt  end  of  the  catheter  being  passed  in  retrograde 
fashion  through  the  catheter  outlet.  The  bladder  is  then  filled  and, 
under  the  guidance  of  the  eye,  the  redundant  portion  of  the  wax-tipped 
catheter  is  slowly  withdrawn,  care  being  taken  that  the  wax  portion 
does  not  come  into  contact  with  metal  or  with  the  deflector.  Catheteri- 
zation  of  the  ureter  and  exploration  of  the  same  are  then  done.  Finally, 
the  instrument  is  withdrawn  first,  the  catheter  following.  A  search  for 
scratch  marks  is  then  made  with  a  pocket  lens.  Hinman  has  recently 
described  an  ingenious  rubber  sheath  which  protects  the  wax-tipped 
catheter  as  it  glides  through  the  operating  cystoscope.8 

In  the  female  it  will  be  found  easiest  to  insert  the  wax-tipped  bougie 
through  the  urethra,  thread  the  sheath  over  it,  and  then  follow  with 
the  catheterizing  telescope. 

Or  if  the  operating  cystoscope  be  not  at  hand,  the  following  technic 
is  applicable:  After  introduction  of  the  sheath  the  wax-tipped  bougie 
protected  with  a  rubber  tube  (which  projects  1  cm.  beyond  the  wax 
tip),  is  made  to  enter  and  manipulated  until  tube  and  bougie  emerge 
through  the  fenestra.  The  bougie  is  then  pushed  a  little  farther  into 
the  bladder,  the  rubber  tube  withdrawn  and  the  telescope  inserted. 

Special  Catheterization. — The  synchronous  employment  of  three  cathe- 
ters or  bougies  is  possible  in  the  operating  cystoscope,  and  useful  in 
cases  of  reduplication  of  the  ureters.  A  very  large  catheter  of  the  Gar- 
ceau  type  may  be  useful  in  pyeloradiography  and  for  drainage  of  a 
pyonephrotic  kidney.  Special  catheters  with  bulbous  enlargements  to 
prevent  reflux  can  be  introduced  through  the  operating  cystoscope,  and 
are  valuable  in  pyelography. 

High-frequency  Treatment  of  Tumors.  —  This  can  be  carried  out 
through  the  catheterizing  cystoscope,  operating  cystoscope  or  cysto- 
urethroscope.  For  the  employment  of  this  method  of  treatment  which 
has  been  variously  termed  desiccation,  fulguration,  electro-coagulation, 
cauterization,  intravesical  cauterization,  Beer  made  use  of  an  insulated 
wire  electrode  which  can  pass  through  the  cystoscope  and  be  made  to 
discharge  the  current  from  a  high-frequency  machine.!  Although  the 

*  Long  whalebone  filiforms  are  useful  but  more  rigid  and  less  easily  handled. 

t  Since  the  introduction  of  the  Buerger  operating  and  combination  cystoscopes,  it  is 
an  easier  procedure  to  guard  the  wax-tipped  bougie  with  a  rubber  tube  placed  in  the 
operating  telescope. 

J  Standard  Nos.  2  and  3  made  by  Wappler  Electric  Manufacturing  Company,  cata- 
logue No.  56,  pp.  41  and  42. 


90  THE  CYSTOSCOPE  AND  ITS  USE 

exact  nature  of  the  effect  of  the  electric  sparks  upon  the  tissues  is  not 
clearly  understood,  we  may  regard  destruction  of  the  tissues  that 
ensues  as  equivalent  to  cauterization.  Two  types  of  current,  the 
Oudin  or  monopolar,  and  the  d'Arsonval  or  bipolar  current  give  almost 
identical  results.  This  procedure  is  applicable  only  in  benign  growths, 
particularly  to  papillomata,  and  must  not  be  carried  out  until  the  exact 
diagnosis  has  been  made  with  the  microscope.  For  this  purpose  a  por- 
tion of  the  tumor  should  first  be  removed  with  the  snare  or  with  the 
punch  forceps  through  the  operating  cystoscope.  Carcinomata  do  not 
respond,  except  perhaps  for  those  small  papillomata  in  which  a  change 
into  carcinoma  is  just  beginning  to  take  place.  When  used  through  the 
cysto-urethroscope  and  operating  cystoscope,  special  electrodes  covered 
with  silk  and  shellac  insulation  will  be  found  more  durable  than  the 
rubber-insulated  wire  first  suggested. 

Dilating  of  the  Ureters  and  Facilitating  the  Descent  of  Ureteral  Calculi. 
— For  strictures  of  the  ureter,  abnormally  narrow  ureteric  orifices,  occa- 
sionally inflammatory  conditions  of  the  ureter  due  to  calculus,  and 
particularly  for  the  purpose  of  expediting  the  descent  of  descending 
ureteral  calculi,  the  dilatation  of  the  ureter  may  be  practised.  With  the 
operating  cystoscope,  we  begin  with  a  small  catheter  or  small  bougie, 
No.  5  French  or  less,  then  insert  a  larger  one,  or  two  or  more  catheters 
or  a  large  bougie.  Somewhat  more  certain  and  effectual  is  the  employ- 
ment of  graduated  metal  olives  at  the  end  of  a  bougie  electrode,  through 
which  the  d'Arsonval  current  may  be  applied.1  Detachable  metal  olives 
are  screwed  on  the  end  of  an  insulated  wire  electrode.  These  can  be 
introduced  after  the  fashion  of  a  ureteral  catheter.  With  a  large 
indifferent  electrode  over  the  lower  abdomen,  the  second  pole  being  the 
metal  olive,  a  current  of  200  to  400  milliamperes  is  allowed  to  pass, 
while  gentle  pressure  is  exerted  against  the  point  of  ureteral  obstruction. 
Often  the  obstruction  gives  way  after  a  few  seconds'  contact.  The 
small  olive  (beginning  with  No.  5  or  6)  is  then  removed,  and  a  larger 
one  inserted,  the  process  being  repeated  until  adequate  dilatation  has 
been  produced.  When  using  the  larger  olives,  it  is  important  that  the 
olive  protrude  beyond  the  objective  and  enter  the  sheath  first,  or  else 
introduction  into  the  sheath  will  fail.  In  many  cases  of  descending 
ureteral  calculi  a  small  stone  will  be  made  to  pass  shortly  after  dilata- 
tion by  this  procedure.  This  may  be  combined  with  the  injection  into 
the  ureter  of  olive  oil  or  glycerin  and  the  employment  of  the  current  is 
not  always  essential.  When  the  ureteric  orifice  is  not  too  small,  the 
procedure  may  be  preceded  by  meatotomy  of  the  ureter. 

The  Removal  of  Foreign  Bodies,  Calculi  and  Phosphatic  Encrustations. — 
The  technic  of  the  removal  of  foreign  bodies  with  the  operating  cysto- 
scope will  depend  upon  their  size,  structure  and  shape.  We  must  be 
guided  in  the  selection  of  the  type  of  forceps  by  these  considerations. 
When  the  body  is  too  large  to  pass  through  the  sheath,  which  is  often 
the  case  with  descending  ureteral  and  also  vesical  calculi,  the  forceps 
with  body  in  its  grasp  is  first  pushed  farther  into  the  bladder  beyond 
the  beak.  The  cystoscope  is  then  rotated  so  that  its  beak  points  up- 


91 

ward,*  and  the  cystoscope,  forceps,  and  body  are  removed  simultane- 
ously, the  foreign  body  being  the  last  to  appear  from  the  urinary  meatus. 
For  the  removal  of  phosphatic  encrustations  in  alkaline  and  ulcerative 
cystitis,  the  operating  punch  forceps  or  a  special  curette  will  be  found 
invaluable  in  clearing  up  an  otherwise  intractable  cystitis.  The  sheath 
must  remain  in  situ  while  the  encrustations  are  removed  piecemeal. 

Ureteral  Meatotomy. — This  may  be  necessary  as  a  preliminary  pro- 
cedure before  dilatation  of  the  ureter  to  facilitate  the  passage  of  a  cal- 
culus; also  in  cases  of  congenital  stenosis  of  the  ureter.  Special  scissors 
are  used  to  cut  the  upper  ureteral  lip. 

Exploratory  Excision  (Intravesical  Biopsy). — We  are  not  infrequently 
confronted  with  alterations  of  the  vesical  mucous  membrane,  whose 
exact  nature  is  doubtful.  For  the  diagnosis  of  certain  cases,  excision 
of  lesions  followed  by  microscopic  examination  may  be  indicated.  In 
the  case  of  suspected  carcinoma  the  removal  of  adequate  pieces,  prefer- 
ably from  the  periphery  of  the  growth,  is  absolutely  imperative.  In  the 
cases  of  suspected  renal  tuberculosis  when  there  are  early  changes, 
such  as  edema  and  polypoid  protuberances  in  the  neighborhood  of  one 
ureteral  orifice,  excision  of  tissue  from  the  ureteral  lip  will  disclose 
miliary  tubercles  under  the  microscope.  When  tubercle  bacilli  are  not 
found,  we  often  can  make  a  diagonsis  in  this  way. 

Snaring  of  Papillomata. — Experience6  has  shown  that  carcinoma  must 
be  ruled  out  in  the  case  of  all  papillomata  by  means  of  histological  ex- 
amination. Whenever  feasible,  therefore,  a  large  part  of  the  growth 
should  be  removed  writh  the  intravesical  snare.  This  can  be  readily 
accomplished  when  the  tumor  has  attained  sufficient  size  and  lies  in 
accessible  portions  of  the  bladder.  In  certain  positions,  such  as  the 
immediate  neighborhood  of  the  sphincter,  the  snare  is  not  applicable. 
Here  the  removal  of  material  by  means  of  the  punch  forceps  through  the 
operating  cystoscope  or  operating  cysto-urethroscope  must  be  substi- 
tuted. The  snare  is  provided  with  a  loop  of  No.  00  piano  wire,  which  is 
developed  by  pushing  out  one  and  then  the  other  of  the  wires.  The 
tumor  is  encircled,  the  end  of  the  cannula  being  carefully  held  against 
the  pedicle  lest  the  papilloma  elude  the  grasp  of  the  loop  as  it  is  being 
drawn  tight.  Because  of  the  peculiar  villous  nature  of  these  growths, 
tumors  of  considerable  size  can  be  forced  through  the  sheath  of  the 
operating  cystoscope. 

Excision  of  Ulcers. — Callous  ulcers  of  the  bladder,  particularly  in 
females,  and  foci  that  are  covered  with  phosphatic  encrustations,  when 
these  cause  an  irritable  bladder,  should  be  treated  with  excision  with 
the  punch  forceps. 

Operations  on  Ureterocele  and  Cystic  Bodies. — When  there  is  an  anoma- 
lous or  congenital  stenosis  of  the  ureter ic  orifices,  or  when  there  is  a 
condition  of  cystic  dilatation  of  the  lower  end  of  the  ureter,  incision 
with  a  special  intravesical  knife  or  with  cystoscopic  scissors,  combined 
with  the  use  of  the  punch  forceps,  may  completely  abolish  the  cause  of 
the  obstruction  and  make  for  drainage  of  the  kidney.4 

*  Rotation  is  unnecessary  if  a  convex  sheath  is  employed. 


92  THE  CYSTOSCOPE  AND  ITS   USE 

URETHROSCOPE  AND  URETHROSCOPY. 

Urethroscopy  deals  with  the  inspection  of  the  male  and  female 
urethra  in  their  entirety.  In  the  male  we  may  arbitrarily  divide  the 
urethra  for  purposes  of  urethroscopy,  into  the  anterior  urethra,  the 
posterior  urethra  and  the  urethrovesical  or  sphincteric  portion.  In 
the  female  we  may  divide  the  canal  into  the  urethra  proper  and  the 
sphincteric  or  urethrovesical  portion. 

The  anterior  urethra  may  be  brought  into  view  in  two  ways :  directly 
with  the  urethroscope,  also  called  endoscope,  and  indirectly  with  tele- 
scopic instruments. 

The  posterior  urethra  may  be  viewed  directly  by  endoscopes  of  the 
straight  or  curved  variety,  indirectly  by  means  of  a  cysto-urethroscope. 

The  sphincter  or  urethrovesical  portion  in  the  male  may  be  poorly 
and  inadequately  viewed  by  means  of  the  direct  method,  thoroughly 
inspected  by  the  indirect  method  through  the  cysto-urethroscope. 

THE  URETHROSCOPE. 

The  simplest  and  most  useful  instrument  for  viewing  the  anterior 
urethra  is  a  tube  into  which  light  can  be  thrown  either  from  without 
by  means  of  a  small  electric  lamp  or  from  within  by  means  of  a  light 
carrier  introduced  into  the  tube  (Fig.  72).  A  small  magnifying  lens  is 
invaluable  to  enlarge  the  picture.  A  set  of  tubes  in  sizes  of  20, 22,  24, 
26,  28,  and  30  French  should  be  available,  Nos.  24,  26,  and  28  being 
the  most  frequently  used.  Although  this  instrument  will  suffice  for 
routine  work  in  the  anterior  urethra,  the  cysto-urethroscope  is  em- 
ployed by  many  for  a  study  of  those  finer  details  that  may  escape 
observation  by  direct  vision. 

Technic  of  Urethroscopy. — The  patient  is  placed  either  in  the  dorsal 
decubitus  with  the  operator  standing  on  his  right  or  in  a  modified 
lithotomy  position  with  the  thighs  horizontal,  the  legs  vertical,  and  the 
feet  supported  upon  a  rest,  in  which  case  the  operator  stands  between 
the  patient's  thighs.  The  former  position  will  be  found  convenient 
for  the  inspection  and  treatment  of  the  anterior  urethra. 

The  set  of  urethroscopes  having  been  boiled,  the  lamp  having  been 
tested,  the  operator  selects  a  tube  of  ample  size,  preferably  24,  26,  or 
28  French.  If  the  meatus  is  too  small,  meatotomy  may  be  done.  After 
cleansing  the  foreskin  and  meatus  the  left  hand  holds  the  penis,  while 
the  endoscope  with  the  obturator  in  place,  previously  lubricated,  is 
allowed  to  find  its  way  into  the  urethra,  until  it  is  arrested  at  the 
bulbomembranous  junction.  The  obturator  is  removed,  the  urethra 
and  tube  mopped  dry  by  means  of  sterile  cotton  applicators,  the  light 
applied,  the  lens  adjusted,  and  the  urethra  is  ready  for  view.  The  left 
hand  continues  to  hold  the  penis  while  the  right  hand  gradually  with- 
draws the  endoscope. 

In  most  cases  local  anesthesia  is  not  recommended  for  simple  observa- 
tion urethroscopy,  because  it  may  produce  anemia  of  the  mucous  mem- 


THE   URETHROSCOPE 


93 


brane,  and  may  wash  away  secretions  whose  source  is  to  be  determined. 
If  painful  operative  procedures  are  to  be  done,  a  2  per  cent,  or  4  per  cent, 
novocain  solution  is  injected  and  allowed  to  remain  in  contact  with  the 
urethra  for  five  minutes. 


FIG.  72. — Urethroscope  for  viewing  the  anterior  urethra:    1.  obturator;  £,  light  carrier 
with  small  lens  attached;  3,  electric  coupling  and  cable;  4<  endoscopie  tube. 


Urethroscopic  Picture. — The  essential  features  of  the  urethroscopic 
view  are  the  character  of  the  central  figure  and  of  the  mucous  mem- 
brane. The  central  figure  is  that  artificial  termination  of  the  urethral 
canal  produced  at  the  far  end  of  the  urethroscope.  By  virtue  of  the 
distending  effect  of  the  endoscope  the  urethral  walls  are  symmetrically 
separated  at  the  level  of  the  end  of  the  tube  and  present,  in  their  gaping 
condition,  a  funnel  whose  outlet  is  made  up  of  the  centre  of  the  urethral 
canal  (the  central  figure)  and  whose  walls  are  the  mucous  membrane 
immediately  in  view.  The  shape  of  the  central  figure  will  vary  in 
different  parts  of  the  canal,  being  a  vertical  slit  in  the  region  of  the  glans, 
being  punctiform  in  the  penile  urethra,  and  becoming  a  more  or  less 
transverse  crevice  farther  down  in  the  canal. 


94 

The  surface  of  the  mucous  membrane  presents  for  consideration  the 
longitudinal  folds,  longitudinal  striae,  the  lacunas  of  Morgagn i,  and  the 
glands  of  Littre. 

The  longitudinal  folds  by  virtue  of  their  disposition  may  be  likened 
to  the  spokes  of  a  wheel  and  become  considerably  altered  by  patho- 
logical changes  in  the  mucous  membrane. 

The  longitudinal  striations  are  the  consequence  of  vascular  ramifica- 
tions, and  are  seen  as  red  converging  markings  on  a  paler,  yellowish-red 
background.  The  surface  of  the  mucous  membrane  is  smooth  and 
shiny,  any  loss  of  brilliancy  being  evidence  of  pathological  change.  The 
lacuna?  of  Morgagni  are  crypts  situated  on  the  superior  roof  of  the  penile 
urethra,  and  their  orifices  can  be  seen  as  minute  depressions  whose 
color  does  not  vary  from  the  surrounding  mucous  membrane  in  the 
normal  state.  The  larger  lacunae  have  orifices  that  are  Y-shaped,  the 
point  being  turned  toward  the  central  figure. 

The  glands  of  Littre  are  very  numerous  and  hardly  recognizable 
except  when  they  have  undergone  pathological  change.  The  Cowper's 
glands  are  rarely  visible  in  the  floor  of  the  bulbous  urethra. 

The  Pathological  Anterior  Urethra. — As  a  result  of  gonorrheal 
inflammation,  two  broad  types  of  lesions  in  the  mucous  membrane 
may  result,  "soft  infiltration"  and  "hard  infiltration." 

Soft  Infiltration. — This  is  characterized  by  a  turgid  condition  of  the 
mucous  membrane,  histologically  by  infiltration  of  the  submucosa  with 
round  cells  and  increased  vascularization.  This  condition  results  or 
accompanies  acute  urethritis,  also  the  earlier  stages  of  chronic  urethritis. 
The  mucous  membrane  is  hyperemic,  inflamed,  turgid,  and  not  unlike 
a  group  of  hemorrhoids.  The  central  figure  is  closed,  the  longitudinal 
strise  disappear,  and  the  longitudinal  folds  are  effaced. 

The  lacuna?  of  Morgagni  and  glands  of  Littre  are  usually  involved, 
their  glandular  secretions  being  increased.  The  mucosa  in  the  imme- 
diate neighborhood  is  a  deeper  red  and  slightly  swollen,  and  the 
excretory  ducts  of  the  Littre  glands  are  more  prominent  than  normal. 

Hard  Infiltration. — This  is  distinguished  by  pallor  of  the  mucosa, 
histologically  by  connective-tissue  proliferation,  the  end-result  of  an 
exudative  cellular  inflammation.  This  corresponds  to  the  condition  of 
"  stricture  of  large  caliber"  described  by  Otis.  The  urethroscopic  tube 
meets  with  a  certain  resistance  in  its  passage  through  such  a  urethra. 
The  walls  present  a  characteristic  rigidity,  having  lost  their  normal 
suppleness.  When  the  endoscope  is  withdrawn  the  central  figure 
gapes  and  the  eye  may  look  down  much  farther  than  in  the  normal 
case.  There  is  notable  diminution  in  the  coloring  of  the  mucosa,  pallor, 
a  grayish-yellow  color  or  even  a  whitish-gray  appearance.  • 

Lesions  in  the  Lacunae  of  Morgagni  and  Littre's  Glands. — Two 
types  of  lesions  must  be  recognized,  the  glandular  form,  or  open  lesion, 
and  a  dry  or  follicular  form,  the  closed  lesion. 

Glandular  Open  Lesions. — Here  the  orifices  of  the  glands  of  Littre  are 
enlarged  and  surrounded  by  an  inflammatory  zone.  A  drop  of  secre- 
tion, sometimes  purulent,  sometimes  clear,  may  be  seen  emanating  from 


THE   URETHROSCOPE  95 

the  orifice.  Similar  changes  are  seen  about  the  lacunae  of  Morgagni. 
Their  orifices  are  crater-like,  and  mucoidal  or  purulent  secretion 
escapes. 

The  Dry  or  Follicular  Form.— When  the  excretory  ducts  are  closed,  the 
glands  become  shut  off  and  secretion  accumulates  so  as  to  form  cystic 
bodies  which  may  harbor  the  gonococcus. 

For  the  more  rare  lesions,  such  as  ulceration,  leukokeratosis,  leuko- 
plakia,  syphilitic  lesions,  chancroid,  varices,  new  growths,  papillomata, 
polyps,  sarcoma,  tuberculosis,  etc.,  special  works  on  urethroscopy 
should  be  consulted. 

Urethroscopy  of  the  Posterior  Urethra. — The  posterior  urethra 
can  be  brought  into  view  in  two  ways :  directly,  through  a  straight  or 
curved  urethroscopic  tube,  and  indirectly,  through  a  cysto-urethroscope 
carrying  a  telescopic  lens  system  (Goldschmidt  or  Buerger). 

With  Endoscopes.- — Two  types  of  instruments  may  be  used  for  this 
puspose:  The  straight  tube  employed  for  inspecting  the  anterior  ure- 
thra, or  the  curved  tube  writh  a  beak  as  suggested  by  Lowenhardt  and 
modified  by  Swinburne.  These  instruments  were  much  in  use  before 
the  development  of  the  cysto-urethroscope,  and,  although  they  still 
have  a  sphere  of  usefulness  in  the  hands  of  those  who  frequently  make 
topical  applications,  they  may  be  regarded  as  being  so  greatly  inferior 
to  the  cysto-urethroscope,  that,  in  our  experience,  they  need  rarely  be 
employed. 

A  useful  type  is  that  in  which  the  lamp  is  carried  in  a  special  groove 
and  does  not  encroach  upon  the  lumen  of  the  tube.  When  it  is  desired 
to  look  into  the  bladder  also  by  direct  vision,  the  Luys  endoscope  is 
recommended  since  the  field  can  be  kept  dry  by  aspiration.  Some 
urologists  find  an  attachment  for  air  inflation  of  the  urethra  of  value. 

Technic: — Writh  the  bladder  empty  and  after  the  application  of  the 
local  anesthetic,  the  patient  is  placed  in  either  the  lithotomy  or  modified 
lithotomy  position,  with  the  inclination  of  the  Trendelenburg  posture 
if  the  Luys  tube  is  employed.  In  the  female  the  knee-chest  position  is 
preferred  by  many.  After  the  patient  has  voided,  the  urethroscope  is 
introduced,  the  urine  aspirated  either  through  a  special  aspirator  or 
through  the  canal  in  the  urethroscopic  tube  or  mopped  out  with  cotton 
applicators,  the  lamp  applied,  and  inspection  is  begun  at  the  internal 
vesical  sphincter.  The  urethroscope  is  withdrawn  gradually,  the  pos- 
terior urethra  being  inspected  as  it  prolapses  into  the  lumen  of  the 
tube.  It  is  difficult  to  avoid  traumatism  in  these  manipulations. 

With  Cysto-urethroscopes. — Since  the  introduction  of  the  telescopic 
variety  of  instrument  for  viewing  the  posterior  urethra  the  direct 
method  has  been  discarded  by  a  large  number  of  urologists.  In 
our  own  opinion  a  cysto-urethroscope  is  to  be  preferred  both  for 
routine  examinations  and  for  therapy,  for  the  following  reasons:  it 
produces  no  trauma,  may  be  easily  introduced,  and  is  very  well  borne 
by  the  patient;  the  view  of  the  ureters,  trigone,  sphincteric,  and  juxta- 
sphincteric  regions  and  posterior  urethra  is  immeasurably  superior 
to  that  obtained  with  any  other  system ;  by  the  use  of  a  constant  flow 


96  THE  CYSTOSCOPE  AND  ITS   USE 

of  irrigating  fluid  that  dilates  the  posterior  urethra  the  to-and-fro  as 
well  as  the  rotatory  motions  of  the  instrument  are  facilitated,  trauma- 
tism  is  obviated,  pain  is  dispelled,  the  urethra  is  unfolded,  and  the 
thoroughness  of  inspection  is  enhanced;  even  the  region  of  the  neck  of 
the  bladder,  almost  inaccessible  in  a  therapeutic  sense  through  other 
instruments,  can  be  attacked  with  ease;  in  the  diagnosis  of  prostatic 
hypertrophy  the  cysto-urethroscope  gives  exact  data  obtainable  with 
no  other  instrument. 

The  Goldschmidt  Instrument. — This  is  made  up  of  a  sheath  with  a 
large  fenestra  whose  width  corresponds  to  the  diameter  of  the  sheath, 
necessitating  the  cutting  out  of  one-half  of  the  circumference  of  the 
tube.  A  non-prismatic  telescope  is  introduced,  the  source  of  illumina- 
tion being  situated  either  in  the  beak  or  in  the  roof  of  the  sheath.  Al- 
though a  fairly  good  view  of  the  urethra  is  obtained  with  this  instru- 
ment, objects  must  necessarily  suffer  considerable  distortion,  owing  to 
the  fact  that  the  part  to  be  seen  is  parallel  with  the  axis  of  the  telescope. 
Then,  too,  the  source  of  illumination  takes  up  a  portion  of  the  field, 
disturbing  the  picture.  Wossidlo  has  modified  this  instrument  so  that 
the  view  and  accessibility  of  the  parts  for  treatment  are  enhanced. 

The  Buerger  Cysto-urethroscope. — T\vo  types  of  instrument  are  avail- 
able, one  for  simple  observation  and  another  for  special  operative  work, 
the  optical  principle  involved  being  the  same  in  both.  In  the  Buerger 
cysto-urethroscope  a  true  picture  of  the  interior  of  the  posterior  urethra 
is  obtained  by  a  special  lens  system,  which  produces  scant  augmentation 
in  the  size  of  near  objects,  and  looks  downward  at  right  angles  upon  the 
field. 

The  observation  instrument  (Fig.  73)  consists  of  a  sheath  with  a 
curved  detachable  beak,  an  obturator,  and  telescope.  In  the  sheath 
there  is  a  small  fenestra,  two  irrigating  cocks,  and  the  source  of  illumina- 
tion is  a  small  lamp  behind  an  obliquely  set  window,  illumination  com- 
ing from  above.  The  telescope  is  provided  with  a  single  catheter  outlet 
and  deflector. 

Technic  of  Cysto-urethroscopy.* — The  sheath  with  obturator  in  situ  is 
introduced  into  the  bladder,  the  obturator  removed,  and  if  the  contents 
of  the  bladder  are  cloudy,  irrigation  is  carried  out  through  the  sheath. 
Otherwise  the  telescope  may  be  inserted  at  once,  an  irrigator  attached 
to  one  of  the  lateral  faucets,  and  a  constant  flow  of  boric  acid  solution 
is  allowed  to  pass  through  the  sheath,  being  controlled  with  the  finger 
of  the  left  hand  at  the  stopcock.  The  light  is  then  turned  on,  the  beak 
turned  up,  the  lens  looking  downward.  The  trigone  is  first  inspected; 
then  the  sphincteric  margin  is  brought  into  view,  the  instrument  being 
rotated  on  its  long  axis.  The  instrument  is  then  gradually  withdrawn 
and  the  posterior  urethra  examined  as  far  as  the  membranous  urethra. 
The  instrument  is  then  introduced  again  beyond  the  sphincter  and  the 
bladder  emptied,  if  it  is  too  full,  either  through  the  irrigating  cock  or  by 
withdrawing  the  telescope.  By  rotation  of  the  instrument  the  superior 

*  With  the  Buerger  cysto-urethroscope. 


THE   URETHROSCOPE 


97 


and  lateral  walls  of  the  posterior  urethra  are  now  viewed.  Finally,  the 
membranous  urethra  and  bulb  are  examined,  and  upon  withdrawing 
the  instrument  the  left  hand  firmly  grasps  the  penis,  so  that  an 
inspection  of  the  anterior  urethra  can  also  be  carried  out. 

In  order  to  facilitate  localization  of  the  findings  obtained  with  the 
cysto-urethroscope,  it  is  expedient  to  divide  up  the  posterior  urethra 
in  an  arbitrary  way,  taking  certain  well-defined  landmarks,  such  as  the 
annulus  urethralis,  or  margin  of  the  internal  sphincter  of  the  bladder, 
and  the  colliculus  seminalis,  in  determining  the  extent  of  each  portion. 
The  subdivisions  that  are  most  useful  in  practice  are  the  following: 


FIG.  73. — Buerger  observation  cysto-urethroscope. 

The  sphincter  margin  with  superior  (roof),  inferior  (floor),  and  lateral 
]x>rtions  (sides);  the  pars  prostatica  (Cr)  and  the  pars  membranacea 
(B)  (Fig.  74). 

We  divide  the  prostatic  urethra  into : 

(1)  Supramontane  portion  between  the  sphincter  margin  and  veru- 
montanum,  with  a  roof,  lateral  walls  (sides),  and  floor  (  U}.  (2)  Mon- 
tane portion  with  a  roof,  sides  and  floor  ( 7"). 

The  floor  of  the  supramontane  portion  shows  the  fossula  prostatica 
(F  P)  and  the  floor  of  the  montane  portion  contains  the  colliculus 
(verumontanum  or  urethral  crest)  and  lateral  sulci  (sulci  laterales). 
If  we  regard  the  complete  ridge  or  verumontanum  as  the  urethral  crest 
(crista  urethralis)  it  seems  best,  for  topographical  reasons,  to  distinguish 
the  following  parts :  posteriorly  (toward  the  bladder)  there  are  usually 
a  number  of  small  bands  that  lie  in  the  fossula  prostatica  and  pass  into 
the  crista  urethralis,  namely,  the  posterior  frenula.  They,  belong  both 

M  U      I — 7 


98 


THE  CYSTOSCOPE  AND  ITS   USE 


to  the  supramontane  portion  and  to  the  montane.  The  crista  shows  a 
posterior  gradual  inclination  or  declive  (S),  a  central  prominence,  or 
summit,  and  the  anterior  distal  slope,  the  acclive  (R).  We  shall  drop 
the  term  urethral  crest  and  speak  only  of  a  verumontanum  or  colliculus 


FIG.  74. — Diagrammatic  subdivision  of  the  posterior  urethra,  the  membranous  urethra, 

and  bulb. 

showing  a  summit,  acclive  (anterior  crista),  and  declive  (posterior 
crista) .  The  valleys  on  either  side  of  the  colliculus  are  the  sulci  laterales. 

The  membranous  urethra  (B)  receives  the  terminating  fold  of  the 
acclive  and  also  has  a  roof,  side  walls  and  floor. 

Normal  Urethroscopic  Picture  (Posterior  Urethra). — The  Supramon- 
tane Region. — The  markings  of  the  floor  are  prolongations  of  those  of 


FIG.  75. — Floor  of  the  sphincter  and  supramontane  urethra. 

the  trigone.  The  floor  descends  toward  the  periphery  and  terminates 
in  the  fossula  prostatica.  The  mucous  membrane  of  this  region  is  of 
a  deeper  red  than  that  of  the  roof  and  sides  of  the  sphincteric  margin. 
As  for  the  markings,  we  usually  find  longitudinal  vessels  which  show  a 


THE   URETHROSCOPE  99 

tendency  to  converge  toward  the  periphery,  taking  their  source  from 
the  sphincteric  margin  and  passing  toward  the  fossula  prostatica 
(Fig.  75). 

The  side  walls  and  roof  present  nothing  worthy  of  note.  The  supra- 
montane  region  contains  a  proximal  and  a  distal  portion.  The  proximal 
part  corresponds  to  the  true  internal  sphincter.  Distally  the  floor  of  the 
pars  supramontana  contains  the  fossula  prostatica,  in  which  lie  the 


FIG.    76. — Normal    type   of    colliculua  Fu;.  77. — -Normal  colliculus,  showing 

(verumontanum) ,  with  large  utricle.  three  vertical  slits,   the  utricle  in  the 

centre  and   the  ejaculatory    ducts    on 
either  side. 

posterior  frenula,  tiny  ridges  which  pass  backward  from  the  foot  of  the 
declive,  diverging  as  they  are  traced  backward  toward  the  sphincter 
and  varying  both  in  number,  in  size  and  inclination. 

At  the  level  of  the  fossula  prostatica  we  begin  to  meet  with  the  larger, 
plainly  visible  prostatic  ducts,  that  hide  in  the  depression  between  the 
posterior  frenula  and  at  the  foot  of  the  declive. 


FIG.  78. — Normal  colliculus,  showing  the  utricle,  the  ejaculatory  ducts,  the  declive  above, 
and  the  posterior  frenula. 

The  Montane  Region. — The  verumontanum  has  a  summit,  a  posterior 
portion  or  declive,  and  an  anterior  portion  or  acclive.  The  size  of 
the  verumontanum  varies  greatly.  The  general  shape  of  the  region, 
too,  is  subject  to  variation,  insofar  as  it  may  sometimes  show  a 
deep  concavity,  and  at  other  times  seems  to  be  almost  filled  by  the 
verumontanum . 

Types  of  verumontanum  are  illustrated  in  Figs.  76,  77  and  78.    In 


100  THE  CYSTOM'OPE  AXD  ITS  USE 

most  the  orifice  of  the  utricle  can  be  distinctly  seen.  It  takes  a  median 
position  not  far  from  the  summit,  varying  in  general  appearance,  some- 
times being  punctiform,  slit-like  (Figs.  76  and  77),  umbilicated,  even  of 
bizarre  form.  Commencing  by  a  fine  tapering  extremity  in  the  mem- 
branous urethra  the  urethral  crest  broadens  in  a  triangular  fashion  as  it 
ascends,  becoming  the  acclive  of  the  colliculus.  In  most  cases  the 
ejaculatory  ducts  can  be  made  out  as  two  symmetrically  situated  ori- 
fices somewhat  below,  distal  and  to  either  side  of  the  utricle.  They  may 
be  vertical  slits  or  may  resemble  the  prominent  eyes  of  a  frog  when  they 
occupy  a  more  lateral  position. 

In  the.  contracted  state  the  color  of  the  colliculus  is  a  pale  yellowish 
red.  A  change  in  color  takes  place  when  upon  artificial  irritation, 
traumatism,  or  psychical  excitation  this  body  becomes  congested. 

The  Sulci  Laterales. — Their  depth  varies  considerably  in  different 
cases.  It  is  in  these  sulci  that  we  find  a  number  of  prostatic  ducts 
varying  from  2  to  6  sometimes  in  the  form  of  tiny  slit-like  openings,  and 
more  frequently  having  a  punctate  shape.  The  mucous  membrane 
here  is  also  of  pale  reddish  yellow  and  the  vascular  markings  are  in  the 
form  of  irregular  longitudinal  streaks  and  tortuous  delicate  vessels. 

As  for  the  side  walls,  these  offer  very  little  of  interest.  In  most  cases 
there  is  a  fairly  abrupt  rise  from  the  sulci,  and  in  other  cases  there  is  a 
concavity  wrhich  is  of  a  somewhat  deeper  red  than  the  floor. 

The  Pars  Membranacea. — As  the  instrument  is  withdrawn  from  the 
montane  region  with  the  fenestra  turned  downward  the  acclive  can  be 
followed  by  its  tapering  crest  into  the  membranous  urethra.  The  longi- 
tudinal markings  are  very  distinct,  as  a  rule,  parallel  or  slightly  con- 
verging vascular  striations  running  distally  on  either  side  of  the  crest 
and  gradually  becoming  lost  in  the  floor  of  the  membranous  urethra. 

The  delicate  median  ridge  of  the  acclive,  as  it  becomes  lost  in  this 
portion  of  the  urethra,  often  shows  a  striking  pallor  at  its  summit  or 
middle,  due  partly  to  the  pressure  effect  of  the 
instrument  and  possibly  also  to  an  avascular 
condition  of  the  part. 

The  Bulbous  Urethra. — The  pars  bulbosa 
may  be  so  large  that  when  distended  with 
fluid  its  distance  from  the  fenestra  and  lamp 
is  considerable  and  illumination  becomes 
diminished.  The  floor  presents  a  corrugated 
appearance  with  occasional  transverse  folds. 
The  roof  and  the  sides  do  not  present  these 
plica?.  A  useful  and  interesting  distal  land- 

theFbuibo9us7ndUpnenZousf  mark  is  afforded  by  the  junction  of  the  bulbous 
urethra;  the  bulb  is  not  and  penile  urethra  (Fig.  79).  The  transverse 
properly  illuminated.  margin  with  the  illuminated  mucous  mem- 

brane below  presents  the  beginning  of  the 

penile  urethra.  On  either  side  the  folded  lateral  wall  and  part  of  the 
floor  of  the  bulbous  urethra  are  seen,  and  the  central  upper  dark 
region  represents  the  poorly  illuminated  distended  bulb. 


THE   URETHROSCOPE  101 

The  Sphincter  Margin. — Three  parts  may  be  considered:  the  vesical 
part,  which  also  belongs  to  the  realm  of  the  right-angled  and  retrograde 
cystoscope;  the  true  margin,  or  ring;  and  the  urethral  portion.  Owing 
to  anatomical  conditions  it  is  impossible,  in  the  male,  to  obtain  a  satis- 
factory view  of  a  small  zone  adjoining  the  roof  of  the  sphincter  (the 
juxtasphincteric  part  of  the  bladder  roof).  The  sphincteric  margin, 
however,  can  be  perfectly  seen  throughout.  Our  inability  to  depress 
the  ocular  of  the  instrument  sufficiently  makes  it  impossible  to  approxi- 
mate the  window  of  the  instrument  near  enough  to  obtain  a  proper 
view  of  an  area  adjoining  the  roof  of  the  sphincter.  At  the  sides,  how- 
ever, this  is  easier,  particularly  if  we  allow  the  bladder  to  collapse.  In 
examining  the  inferior  aspect  of  the  vesical  portion  of  the  sphincter  we 
encounter  no  difficulty,  for  the  transition  from  trigone  to  floor  of  the 
vesical  sphincter  is  a  gradual  one,  and  there  is  no  sudden  drop  or 
sudden  concavity  such  as  is  characteristic  for  the  roof  and  sides.  In 
the  female  these  obstacles  do  not  obtain,  the  urethra  being  short  and 
the  instrument  having  perfect  freedom  of  motion.  In  the  picture  of  the 
floor  (Fig.  75)  there  is  an  upper  portion  which  is  relatively  dark  and 
represents  the  poorly  illuminated  bladder.  Below  this  is  the  beginning 
of  the  floor  of  the  pars  supramontana  with  its  slightly  convex  margin, 
the  internal  orifice  or  floor  of  the  sphincteric  margin.  The  color  of  this 
part  is  a  fairly  deep  red  admixed  with  yellow,  and  the  vascular  markings 
run  in  a  longitudinal  direction  with  a  tendency  to  converge  toward  the 
urethra.  I  n  the  picture  of  the  sides  of  the  sphincter  we  note  the  absence 
of  vascular  markings  and  a  relative  pallor  as  compared  with  the  floor. 
A  slight  concavity  is  the  rule.  The  sides  are  usually  counterparts 
(Fig.  80),  but  the  roof  of  the  sphincteric  margin  often  represents  a  more 
acute  angle. 

Pathological  Lesions. — Just  a  bare  mention  of  some  important 
lesions  can  be  made  here.  A  more  complete  description  may  be  sought 
in  special  monographs.2 

Sphincteric  or  Urethrovesical  Lesions. — Cystitis  colli,  lesions  of  gonor- 
rheal  urethrocystitis,  edema,  leukoplakia,  urethritis  cystica  (Fig.  81), 
cystitis  proliferans,  papillomata,  anomalies,  early  incisure,  and  lobe 
formation  indicating  hypertrophy  of  the  prostate,  the  tabs  following 
healed  proliferative  processes — all  these  can  be  distinctly  made  out. 

The  supramontane  region  is  the  favorite  site  of  urethritis  proliferans, 
which  is  characterized  by  hypertrophy  of  the  mucous  membrane,  bul- 
bous knobs,  thickenings  resembling  small  cysts.  Widely  dilated  crypts 
occur  as  a  sequel  of  gonorrhea. 

In  urethritis  chronica  cystitica  the  formation  of  cysts  or  edematous 
bodies  is  common,  and  these  may  involve  any  portion  of  the  supra- 
montane  or  montane  urethra.  The  cystic  changes  may  be  so  extensive 
as  to  involve  the  whole  of  the  fossula,  even  converting  the  verumon- 
tanum  into  a  cystic  or  edematous  mass  (Fig.  82) . 

In  the  montane  region  the  lesions  of  the  verumontanum  are  important : 
hyperemia,  swelling,  distortion,  excrescences,  enlargement,  a  velvety 
appearance,  absence  of  vascular  markings,  disappearance  of  the  open- 


102 


THE  CYSTOSCOPE  AND  ITS  USE 


ings  of  the  ejaculatory  ducts,  while  the  utricle  remains  visible,  etc.  As 
a  result  of  posterior  urethritis,  the  mucous  membrane  of  the  verumon- 
tanum  loses  its  smoothness,  often  developing  cock's  comb-like  vegeta- 
tions. Intense  changes  with  conversion  of  the  summit  of  the  verumon- 
tanum  into  a  deep  crater  (Fig.  83)  and  other  distortions  result  from  the 
rupture  of  abscesses. 


FIG.  80. — Right  margin  of  the 
sphincter. 


FIG.  81. — Cystic  changes  at  the  right 
margin  of  the  sphincter. 


In  our  experience,  enlargement,  hyperemia,  and  inflammation  of  the 
colliculus  are  not  as  frequent  as  one  would  suppose  from  the  writings 
of  those  who  have  relied  upon  direct  endoscopic  examination. 

As  a  result  of  repeated  instrumentation,  traumatism,  or  chronic 
urethritis  the  verumontanum  suffers  marked  alterations.  A  number  of 
knob-like  masses  may  be  all  that  is  left  of  it ;  peculiar  bands  may  divide 
it  into  irregular  portions,  or  it  may  almost  completely  disappear  through 
atrophy. 


FIG.  82. — Cystic  changes  in  the 
verumontanum. 


FIG.  83. — Atrophy  of  the  verumon- 
tanum with  crater  formation  due  to 
rupture  of  an  abscess. 


Deep  scars  in  the  montane  (Fig.  84)  and  supramontane  urethra  are 
the  sequels  of  instrumentation,  perforation,  and  rupture  of  prostatic 
abscesses,  traumatism  and  operations  for  stricture.  Papillomata  are 
not  uncommon,  particularly  near  the  summit  of  the  colliculus,  and 
polyps  of  the  lateral  walls  and  membranous  urethra  are  not  rare. 

In  the  membranous  and  bulbous  urethra  strictures  of  large  caliber 


THE  URETHROSCOPE 


103 


with  their  transverse  bands  and  ridges  are  frequently  demonstrable. 
Stricture  usually  form  shelf-like  projections  in  the  floor,  sometimes 
extending  over  either  lateral  wall,  with  white  crow's  foot-like  lateral 
offshoots. 

In  prostalic  hypertrophy  the  cysto-urethroscope  will  demonstrate  the 
very  earliest  submucous  adenoma  formations.     The  outline  of  the 


FIG.  84. — A  deep  scar  and  large  crypt 
in  the  right  sulcus  lateralis  and  distor- 
tion of  the  colliculus. 


Fus.  85. — Floor  of  the  sphincter  in 
so-called  lateral  lobe  hypertrophy 
(prostatic  adenoma). 


sphincter  will  present  either  an  intrusion  at  the  site  of  the  submucous 
adenoma,  or  a  distinct  incisure,  often  at  the  floor,  roof,  or  sides  of  the 
sphincter.  Such  clefts  indicate  the  convergence  of  two  contiguous 
adenomata  or  "lobes."  As  a  rule,  in  cases  of  so-called  "lateral 
lobe  hypertrophy"  the  normal  convex  line  at  the  floor  of  the  sphincter, 
is  replaced  by  two  distinct  rounded  bodies  (Fig.  85).  These  can  be 
traced  into  the  supramontane  urethra  where  they  look  like  two 


FIG.  86. — Lateral  lobe  hypertrophy 
in  the  supramontane  region  viewed  with 
the  cysto-urethroscope. 


FIG.  87. — Lateral  lobe  hypertrophy: 
view  just  above  the  verumontanum; 
the  latter  is  small. 


large  vocal  chords,  separated  by  a  deep  cleft  (Fig.  86).  Even  the 
termination  of  these  lobes  in  the  membranomontane  region  can  be 
found,  and  the  verumontanum  will  appear  much  reduced  in  size 
(Fig.  87).  A  middle  lobe  may  be  combined  with  the  lateral  or  may  be 
present  alone.  Its  presence  is  easily  recognized  at  the  floor  of  the 
sphincter. 


104  THE  CYSTOSCOPE  AXD  ITS   USE 

Operative  Urethroscopy. — This  includes  all  therapeutic  procedures 
that  are  applicable  through  either  a  urethroscope  or  cysto-urethroscope. 

In  the  Anterior  Urethra. — Very  few  instruments  will  suffice  to  do  all 
the  necessary  therapeutic  work  in  the  anterior  urethra.  Cotton  appli- 
cators, preferably  on  wooden  handles,  a  fine  probe,  an  electrolytic 
needle,  a  high-frequency  applicator  and  an  operat've  punch  and  alli- 
gator forceps  should  be  available. 

The  lacunae  of  Morgagni  and  glands  of  Littre  may  be  destroyed 
either  with  the  electrolytic  needle  or  with  the  high-frequency  electrode, 
the  aim  being  to  burn  through  the  inner  wall  of  the  lacuna?  or  glands, 
so  as  to  leave  a  wide  avenue  of  communication  with  the  urethra!  lumen, 
or  to  completely  destroy  the  glands.  Under  special  circum  stances  a  small 
Kollmann  knife  may  be  of  value  in  incising  closed  inflammatory  foci.10 

In  the  Posterior  Urethra. — The  straight  urethroscope,  the  Swinburne, 
the  Goldschmidt,Wossidlo,  or  the  Buerger  instruments  may  be  employed. 

Through  urethroscopes  (endoscopes)  the  following  manipulations 
have  been  suggested:  the  application  of  silver  nitrate  in  the  strengths 
of  5,  10,  15  and  20  per  cent,  to  lesions  in  the  posterior  urethra;  cauteri- 
zation of  polypi  and  papillomata  with  galvanocautery  or  the  high- 
frequency  current;  incision  of  cysts  or  closed  suppurative  foci  with  a 
knife;  the  injection  of  the  utricle  with  silver  solutions  through  a  special 
cannula;  and  the  removal  of  foreign  bodies  with  forceps.  All  of  these 
procedures  can  be  carried  out  by  experts,  but  will  be  found  difficult  of 
execution  through  mere  endoscopes.  Practically  all  necessary  manipu- 
lations can  be  more  easily  learned  and  more  precisely  executed  with 
the  operating  cysto-urethroscope. 

Operating  Cysto-urethroscopes. * — These  are  of  two  types,  the  indirect 
(prismatic)  and  direct  (non-prismatic).  The  general  construction  (Fig. 
88)  of-  the  indirect  type  is  the  same  as  that  of  the  observation  cysto- 
urethroscope,  except  that  the  fenestra  and  the  catheter  outlet  are  larger, 
both  being  ample  for  the  insertion  of  operating  devices.  The  lamp  is 
arranged  to  give  adequate  illumination  in  the  bladder  as  well  as  in  the 
urethra.  Synchronous  catheterization  of  the  ureters  is  possible,  either 
through  the  operating  telescope  or  through  a  special  telescope f  pro- 
vided with  two  smaller  outlets,  and  a  fin  to  separate  the  catheters. 

Technic  and  Application. — With  the  operating  punch  forceps  the  following  thera- 
peutic and  diagnostic  procedures  are  possible:  (1)  the  removal  of  excrescences,  inflam- 
matory hypertrophies,  and  inflammatory  polypi  at  the  vesical  sphincter  and  in  the 
urethra;  (2)  the  ablation  of  polypi  and  papillomata  in  the  urethra  of  the  male  (this 
can  be  carried  out  in  a  few  seconds  and  will  be  found  much  easier  technically  than 
through  a  straight  tube);  (3)  the  removal  of  pieces  cf  tissue  for  diagnosis;  (4)  the 
opening  of  the  superior  wall  of  the  utricle  when  this  harbors  inflammatory  exudate, 
the  injection  of  silver  solutions  being  less  efficacious;  (5)  the  application  of  the  high- 
frequency  current  through  a  special  electrode!  (the  d'Arsonval  current  is  preferred). 

One  of  the  most  useful  fields  for  the  application  of  the  operating 
cysto-urethroscope  is  in  the  treatment  of  papillomata  at  the  sphincteric 

*  Buerger  Operating  Cysto-urethroscope,  Wappler  Electric  Manufacturing  Company, 
catalogue  59,  p.  11;  and  Buerger  universal  cysto-urethroscope. 

t  This  may  be  obtained  by  special  order  from  the  Wappler  Electric  Mfg.  Co. 

J  Bugbee  electrode,  Wappler  Electric  Manufacturing  Company,  catalogue  59,  p.  16. 


THE  URETHROSCOPE 


105 


margin  and  for  the  diagnostic  removal  of  pieces  of  tumor  in  this  region. 
The  application  of  medicaments  to  the  posterior  urethra  through 
the  operating  cysto-urethroscope  is  carried  out  as  follows:  After  the 
lesion  is  recognized  the  sheath  is  firmly  held  with  the  left  hand  in  the 
position  in  which  the  lesion  was  found,  while  the  telescope  is  removed 
and  the  fluid  aspirated  or  mopped  out  of  the  sheath.  Then  the  medi- 
cated applicator  is  introduced. 


Fie.  88. — Buerger's  operating  cysto-urethroscope.  This  instrument  has  recently  been 
constructed  according  to  Buerger's  specifications  of  a  caliber  equivalent  to  21  French,  a 
useful  instrument  in -case  of  stricture  and  prostatic  adenoma. 

Buerger's  Universal  Cysto-urethroscope. — This  instrument  employs  the  Goldschmidt- 
Xit/.o  typo  of  direct  non-prismatic  telescope  in  a  specially  designed  endoscopic  tube,  and 
is  so  constructed  that  by  interchange  of  its  parts  it  is  available  either  as  a  cysto-urethro- 
scopi-f  )[•  the  anterior  urethra,  an  air-inflating  or  aero-urethroscope,  a  posterior  urethro- 
scope  or  cysto-urethroscope  of  the  irrigating  type,  a  Kelly  cystoscope,  an  Elsner-Braasch 
cystoscope,  and  a  direct  catheterizing  cystoscope  and  operating  cystoscope.  It  consists  of 


FIG.  89. — Buerger's  universal  urethroscope  with  Philip's  filiform  bougie  for  treatment 
of  strictures  of  the  urethra. 

a  straight  endoscopic  tube  (Fig.  89),  an  obturator  for  the  anterior  urethra,  a  curved  obtu- 
rator for  the  posterior  urethra  and  bladder,  a  light-carrying  tube,  a  telescope,  and  a  magni- 
fying window.  The  endoseopic  tube  carries  a  large  catheter  outlet  for  the  introduction  of 
operating  devices,  applicators,  catheters,  etc.,  and  permits  of  the  introduction  of  either 
of  the  two  obturators  and  also  the  light-carrying  tube.  Either  the  direct  non-prismatic 
telescope  or  the  magnifying  window  fit  into  the  ocular  end  of  the  light-carrying  tube. 


106  THE  CYSTOSCOPE  AND  ITS  USE 

Ter,hnic. — The  sheath  fitted  with  the  curved  obturator  for  the  bladder  and  posterior 
urethra  or  the  short  obturator  for  the  anterior  urethra  is  introduced,  and  when  the 
bladder  and  posterior  urethra  are  to  be  inspected  the  obturator  is  removed,  the  bladder 
emptied  and  irrigated  through  the  sheath.  The  light-carrying  tube  and  telescope  are 
then  locked  into  place,  and  the  irrigating  fluid  is  allowed  to  flow.  The  trigone  and 
ureters  come  into  view  and  the  ureters  may  be  catheterized  according  to  the  direct 
method.  The  instrument  is  withdrawn,  the  trigone,  the  sphincteric  region,  the  supra- 
montane,  montane,  membranous,  bulbous,  and  penile  urethra  are  inspected,  a  sort  of 
perismjiir  view  being  obtained  of  the  neck  of  the  bladder  and  urethra.  This  instrument 
will  be  found  particularly  useful  in  the  recognition  and  treatment  of  filiform  strictures 
of  the  urethra. 

Urethroscopy  in  the  Female. — The  Kelly  type  of  .endoscope  answers 
for  work  in  the  urethra  itself.  For  the  juxtasphincteric  margin,  how- 
ever, the  operating  cysto-urethroscope  is  to  be  preferred. 

Selection  of  Cystoscopes,  Urethroscopes,  and  Cysto-urethroscopes. — In 
the  vast  majority  of  cases  (more  than  99  per  cent.)  the  Buerger  com- 
bination cystoscope  with  two  sheaths  will  suffice  for  observation  and 
ureteral  catheterization.  A  No.  18  French  single  catheterizing  and  a 
21  French  Buerger  catheterizing  cystoscope  are  useful  when  small  cali- 
ber is  desirable.  In  children  a  small  Nitze  or  Otis-Nitze  (10  or  12 
French)  for  observation,  a  single  catheterizing  (17  or  18  French),  and 
Buerger's  smallest  15  French  single  catheterizing  have  their  sphere  of 
application. 

In  special  cases,  such  as  contracted  bladder,  in  prostatic  hypertrophy 
for  study  of  the  sphincteric  region,  and  when  the  posterior  urethra, 
too,  must  be  attacked,  the  operating  cysto-urethroscope  is  to  be  used. 
It  combines  the  possibility  of  operative  work  with  synchronous 
ureteral  catheterization  either  through  its  operating  telescope  or 
through  a  special  telescope  carrying  a  fin  and  two  catheter  outlets. 

\Yhenever  we  desire  to  combine  ureteral  catheterization  with  any 
endovesical  operative  procedure,  an  operating  cystoscope,  or  the 
combination  operating  cystoscope  (p.  86)  should  be  selected. 

For  inspection  of  the  anterior  urethra  the  straight  tubes  (Valentine, 
Squier,  Luys,  or  Young)  are  admirable.  For  the  posterior  urethra 
the  Loewenhardt,  Swinburne,  or  Luys  find  adherents.  The  cysto- 
urethroscope  is  best  in  our  opinion.  In  treating  the  posterior  urethra 
the  two  types  of  Buerger  operating  cysto-urethroscope  are  recom- 
mended. For  Buerger's  method  of  treating  filiform  strictures  of  the 
urethra  the  direct  non-prismatic  universal  cysto-urethroscope  should 
be  employed. 

BIBLIOGRAPHY. 

1.  Buerger:  Am.  Jour.  Surg.,  April,  1913. 

2.  Buerger:  Am.  Jour.  Urol.,  January,  1911;  loc.  cit.,  January,  1912. 

3.  Buerger:  Ann.    Surg.,    February,    1909. 

4.  Buerger:  Med.  Rec.,  June  21,   1913. 

5.  Buerger:  New  York  Med.  Jour.,  April  1,  1911;  Am.  Jour.  Urol.,  September,  1911. 

6.  Buerger:  Surg.,  Gyn.  and  Obst.,  August,   1915. 

7.  Frank:  Med.  Klinik,  1907,  No.  12. 

8.  Hinman:  Jour.  Am.   Med.   Assn.,   June  26,    1915. 

9.  Kelly:  Johns  Hopkins  Hosp.  Bull.,  1893,  iv,  101;  Am.  Jour.  Obst.,  xxix,  1. 

10.  Oberlander-Kollmann :    Die    chronische    Gonorrhoe    der    mannlichen    Harnrohre, 
Leipzig,  1910. 


CHAPTER  III. 

METHODS  OF  DIAGNOSIS  IX  LESIONS  OF  THE  URINARY 

TRACT. 

BY  BRAXSFORD  LEWIS,  M.D. 

Introduction. — The  following  general  remarks  on  genito-urinary 
diagnosis  may  be  looked  on  by  some  as  an  innovation  not  sanctioned  by 
custom,  and  one  hardly  appropriate  to  a  scientific  treatise  for  urologists. 
But  when  it  is  understood  that  they  are  written  for  the  advancement  of 
the  scientific  aspects  of  urology — to  bring  up  and  straighten  out  the 
irregular  marching  lines  where  they  are  hesitant  and  lagging;  when  it 
is  understood  that  they  are  written  from  the  stand-point  of  the  earnest 
student  of  facts  and  causes;  and  that  the  conscientious  hope  exists 
that  they  may  throw  some  light  on  the  vital  and  glaring  question,  why 
so  many  failures  in  genito-urinary  diagnosis  continue  to  appear,  not- 
withstanding that  this  is  an  era  of  ample  instrumental  equipment  and 
well-organized  technic  for  the  successful  practice  of  urology — it  is 
hoped  that  these  remarks  may  seem  timely  and  appropriate.  But 
especially  is  it  desired  that  they  may  be  received  in  the  spirit  in  which 
they  are  tendered,  as  having  the  sincere  purpose  of  being  serviceable 
and  practically  beneficial  to  all  concerned — to  patient,  specialist,  and 
practitioner. 

In  further  explanation,  it  might  be  said  that  the  writer  esteems 
diagnosis  as  the  most  important,  by  far,  of  all  the  subjects  of  urology; 
and  he  believes  that  anything  that  contributes  to  a  better  under- 
standing of  its  general  principles,  its  successes  or  its  failures,  should 
promote  the  interests  of  urology  from  its  foundation  up. 

SOME  VITAL  TRUTHS  REGARDING  GENITO-URINARY  DIAGNOSIS. 

Diagnosis  in  urology  has  experienced  mutations  and  phases  of  evolu- 
tion just  as  have  other  departments  of  medicine  and  surgery. 

While  in  ancient  times  Hippocrates  and  Cornelius  Celsus  pursued 
logical  though  primitive  methods  in  reckoning  diagnoses  and  applying 
their  deductions  to  the  treatment  of  urinary  retention,  stone,  and  other 
genito-urinary  affections,  it  remained  for  the  later  period  of  medi- 
evalism to  witness  the  most  extreme  exploitation  of  the  urine  as  an 
index  of  disease.  Guiteras1  relates  that  at  this  period  (about  the 
fifteenth  century)  examination  of  the  urine  was  resorted  to  not  only 
by  the  regular  practitioner  and  the  university  graduate,  but  also  by 
the  school  of  quacks,  known  as  uromancers  or  uroscopists.  These 

(107) 


108     METHODS  OF  DIAGXOHIH  I\  LEMOXX  OF  I'RIXARY  TRACT 

quacks  would  gravely  inspect  urine  passed  into  glass  flasks  and  imme- 
diately guess  the  illness  and  temperament  of  the  patient,  and  then  base 
a  miraculous  cure  thereon.  While  the  modern  trend  is  hardly  so 
materialistic  as  this,  it  is,  nevertheless,  a  fact  that  there  have  been 
marked  changes  in  that  direction  in  methods  of  investigation  for  devel- 
oping diagnoses,  even  during  the  last  quarter-century.  Previous  to 
that  time  investigators  of  greatest  acumen  had,  perforce,  to  resort  to 
and  rely  on  the  evidences  then  attainable  in  genito-urinary  diseases, 
which  consisted  mainly  of  symptomatology  plus  the  external  evidences 
observable  and  an  examination  of  the  urine.  Under  the  stress  of  neces- 
sity urologists  became  most  skilful  in  refined  analysis  of  symptoms, 
weighing  at  its  full  value  every  deviation  from  the  normal  either  as 
detected  by  them  or  as  related  by  the  patient;  the  art  of  deduction 
doubtless  reached  its  ultimate  degree  of  perfection  in  the  hands  of 
Ricord,  of  Fournier,  Guyon,  Sir  Henry  Thompson,  and  Ultzmann. 
The  contributions  of  Guyon  fairly  scintillate  with  logic  and  acumen  as 
they  relate  the  diagnostic  estimate  to  be  placed  on  the  symptoms  of 
urinary  tuberculosis,  urinary  lithiasis,  "painful  cystitis,"  etc.  But  the 
trouble  came  when  there  were  no  symptoms  to  analyze;  when  there 
were  kidneys  destroyed  by  stone  and  never  a  backache;  when  there 
was  pus  in  urine  and  little  to  indicate  its  source;  hematuria  and  no 
index  of  its  causation  or  its  point  of  origin.  The  difficulties  of  the  situa- 
tion were  enhanced  by  reason  of  the  fact  that  the  genito-urinary  organs, 
hidden  more  or  less  in  the  body,  were  inaccessible  to  the  means  of 
research  then  available;  and  reliance  was  limited  to  the  examination 
of  the  only  factor  that  was  at  hand,  namely,  the  urinary  excretion. 

There  can  be  no  doubt  that  accurate  and  comprehensive  diagnosis 
has  been  the  most  influential  factor  in  the  establishment  of  urology 
on  the  scientific  and  satisfactory  plane  on  which  it  rests  today.  It  was 
the  turning  of  the  patient  inside  out,  so  to  speak,  and  the  plain  demon- 
stration of  the  cause  and  nature  of  his  complaints  by  means  of  the 
various  instruments  of  diagnostic  precision,  that  has  accomplished  the 
miracle  of  evident  progress;  that  has  developed  urology  from  venere- 
ology;  that  has  won  this  field  from  the  domain  of  obscurity  and  empiri- 
cism to  one  of  science  and  accomplishment. 

Nevertheless,  while  urology  as  a  specialty  has  progressed  in  the  man- 
ner and  extent  mentioned,  it  cannot  be  said  that  the  general  profession 
has  kept  pace  with  its  progress.  The  chief  basis  for  this  remark  lies  in 
the  countless  number  of  genito-urinary  patients  who  suffer  needlessly 
from  month  to  month  and  year  to  year — ten,  twenty  or  more  years, 
often — wrhile  under  the  care  of  practitioners  who  go  no  further  in  efforts 
at  relief  than  to  supply  various  "favorite  prescriptions"  for  urinary 
symptoms  or  complaints.  Instead  of  giving  undivided  attention  to 
efforts  at  learning  the  source  and  causation  of  a  hematuria,  they 
supply  drugs  and  measures  for  stopping  the  bleeding,  which  is  the 
worst  object  that  could  be  accomplished  by  them  at  that  time.  Instead 
of  learning  the  origin  and  nature  of  an  infection,  they  are  industriously 
and  empirically  supplying  "internal  antiseptics,"  vaccines,  or  urinary 


VITAL  TRUTHS  REGARDING  GEN ITO-URI NARY  DIAGNOSIS     109 

soothing  syrups,  that  palliate,  perhaps,  but  incidentally  postpone  the 
day  of  definite  diagnosis  and  effectual  relief.  The  patient  may,  indeed, 
have  cause  for  self-gratulation  if  he  is  not  incidentally  conducted,  mean- 
time, from  a  benign  into  a  malignant  period  of  gro"wth  in  the  bladder, 
passing  from  a  condition  amenable  to  treatment  into  one  beyond  relief 
or  ho'pe.  When  he  is  finally  referred  for  the  examination  that  has  been 
long  deferred  or  ignored,  he  is  found  to  be  beyond  all  human  aid  save 
that  of  palliating  his  progress  to  the  grave.  The  failure  of  relief  in  an 
infinite  number  of  such  cases  is  due,  not  to  obscurity  of  the  disease  or 
difficulty  in  diagnosis,  but  to  the  fact  that  no  effort  to  attain  a  real 
diagnosis  is  systematically  or  methodically  made  or  even  advised.  The 
precious  time  is  spent  on  so-called  treatment,  and  a  wonderful  oppor- 
tunity is  wasted.  If  members  of  the  profession  could  collectively 
realize  the  truth  and  import  of  these  facts  they  could  better  appreciate 
the  incalculable  importance  of  genito-urinary  diagnosis  as  compared 
with  immature  and  ill-based  therapy,  and  would  oftener  refrain  from 
the  reversed  action  alluded  to. 

It  is  believed  that  so  great  is  the  importance  of  this  matter  that  an 
awakening  and  reformation  of  the  profession  in  this  respect  would  not 
only  redound  to  its  benefit  in  scientific  progress,  but  would  markedly 
subtract  from  the  sum  total  of  human  misery  as  well  as  add  materially 
to  the  span  of  human  life. 

There  is  one  thought  in  this  connection  that  cannot  be  suppressed  or 
overlooked:  Whenever  a  practitioner  of  medicine,  either  general  or 
special,  undertakes  the  care  of  a  patient,  he  assumes  responsibilities 
that  he  cannot  avoid ;  he  takes  on  the  moral  obligation  to  supply  or  to 
have  supplied  to  that  patient  all  means  and  mechanisms  at  the  disposal 
of  the  profession  that  are  necessary  for  securing  the  relief  desired,  and 
this  whether  the  practitioner  is  himself  capable  of  using  them  or  not. 
Lack  of  familiarity  with  the  use  of  the  a*-ray  machine,  or  failure  to 
possess  one,  does  not  excuse  him  for  depriving  his  patient  of  the  advan- 
tages of  such  a  machine  when  needed.  The  same  reasoning  applies  to 
the  ophthalmoscope,  or  the  cystoscope  or  any  other  of  the  parapher- 
nalia so  useful  and  often  so  essential  in  modern  medicine  and 
surgery. 

Another  broad  fact  of  importance  in  this  connection  is  that  no  prac- 
titioner who  undertakes  the  care  of  such  cases  has  the  right  to  disclaim 
knowledge  of  the  appliances  used  in  the  various  specialties,  and  on  that 
account  justify  himself  for  emitting  the  false  doctrine  that  "nothing 
else  can  be  done"  in  a  given  case.  No  one,  in  the  author's  humble 
opinion,  has  the  right  to  make  any  such  ex-cathedra  statement,  and 
many  a  poor  patient  has,  doubtless,  been  assisted  to  his  grave  on  account 
of  it.  A  better,  truer,  and  more  serviceable  axiom  would  be:  Some- 
flung  can  always  be  done.  And,  it  might  be  further  remarked,  mainly 
through  diagnosis. 

As  to  the  causes  of  backwardness  and  inadequacy  in  genito-urinary 
diagnosis,  it  is  probable  that  a  part  of  the  difficulty  lies  in  the  fact  that 
the  methods  and  technic  of  genito-urinary  examinations,  being  of 


110     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

comparatively  recent  development,  are  not  yet  familiar  to  the  pro- 
fession at  large,  or  that  they  assume  formidable  proportions  in  the 
perspective  of  infrequent  use  or  lack  of  practical  experience. 

As  a  matter  of  fact,  for  most  genito-urinary  diseases  the  demands  of 
serviceable  diagnosis  are  easily  met  and  may  be  carried  out  by  anyone 
who  possesses  a  logical  mind  and  a  reasonable  acquaintance  with  labora- 
tory technic.  This  remark,  of  course,  does  not  apply  to  the  more  re- 
fined and  difficult  steps  of  investigation,  such  as  those  of  endoscopy, 
cystoscopy,  etc.  But  for  the  ordinary  investigation  the  greatest  lapse 
seems  to  be  in  the  lack  of  a  formulated  plan  for  pursuing  the  examina- 
tion. 

Relative  Value  of  Symptoms  and  of  Physical  Examination  for 
Diagnosis. — There  should  be  no  denial  of  the  value  of  a  well-rounded 
and  carefully  studied  history  of  a  genito-urinary  case.  Symptoms  are 
often  typical  and  characteristic  of  certain  maladies,  and  lead  to  ready 
deductions  that  prove  correct  on  applying  the  steps  of  investigation 
without  which  no  genito-urinary  diagnosis  should  ever  receive  con- 
sideration. But  in  many  instances  urinary  symptoms  are  not  typical, 
are  not  regular,  do  not  conform  to  what  would  be  expected  of  them  or 
harmonize  with  the  actual  pathological  conditions  as  later  demonstrated 
by  postmortem  examination  or  otherwise.  In  many  such  cases  the 
symptoms  are  unconventional  and  misleading.  In  renal  cases,  for  in- 
stance, pain  may  arise  apparently  from  the  healthier  of  two  diseased 
kidneys;  or,  indeed,  acute  and  severe  pain  may  be  thus  transposed 
from  a  totally  diseased  to  a  healthy  kidney  of  the  opposite  side.  If 
symptoms  were  to  be  accredited  in  such  cases  without  the  test  of  search- 
ing physical  examination,  it  would  readily  lead  to  disastrous  conse- 
quences. In  fact,  it  has  led  to  disastrous  consequences  in  actual 
experience.  These  are  facts  well-known  to  all  practitioners  of  experi- 
ence in  urology. 

Method  in  the  Quest  for  Diagnosis. — A  certain  prescribed  plan  of 
investigation  should  be  carried  out  in  every  case  of  chronic  urinary 
disorder,  and  all  the  steps  should  be  included  up  to  the  point  at  which 
the  diagnosis  is  not  only  made  but  completed. 

In  a  given  case  of  urethritis,  for  instance,  it  is  necessary  to  learn,  not 
only  the  nature  of  the  infection — as  to  whether  gonococcal  or  not — but 
also  whether  the  posterior  urethra  is  involved,  and  the  prostate,  and 
seminal  vesicles,  and  all  other  parts  of  the  body  subject  to  such  microbic 
invasion.  The  omission  of  either  one  of  these  features  of  diagnosis 
would  be  as  serious  an  oversight  as  the  omission  of  the  other.  To  find 
gonococci  in  a  urethral  discharge  and  then  treat  the  anterior  urethra 
only,  failing  to  recognize  and  treat  the  infected  posterior  urethra  as 
well,  would  be  like  putting  a  splint  on  one  of  two  broken  legs  and 
neglecting  the  other.  That  very  tendency  of  many  to  ignore  the  post- 
urethral  infection  has  probably  been  the  most  prolific  source  of  failure 
in  the  treatment  of  gonorrheas,  as  was  pointed  out  by  the  author  as 
early  as  1893  ;2  and,  similarly,  with  the  diagnosis  of  prostatic  obstruc- 
tion, certain  factors  are  absolutely  essential  to  a  serviceable  diagnosis 


VITAL  TRUTHS  REGARDING  GEN  I  TO-URINARY  DIAGNOSIS     111 

and  nothing  short  of  them  all  will  suffice.     They  must  include  definite 
information  as  to  whether: 

1 .  The  prostate  is  hypertrophied  or  atrophied  ? 

2.  Whether  there  is  obstruction  to  urination? 

3.  If  so,  the  relative  amount  of  obstruction? 

4.  The  form,  physical  characteristics  and  nature  of  the  obstruction? 
">.  The  physical  condition  and  functional  activity  of  the  allied  organs 

(especially  heart  and  kidneys). 

To  illustrate  why  it  is  necessary  to  learn  all  of  these  individual 
features  in  prostatic  obstruction,  it  may  be  mentioned  that  no  one  could 
determine  the  proper  measures  for  relieving  such  a  case  without  first 
learning  the  several  points  of  diagnosis  mentioned  and  then  acting  on 
that  precise  information.  And  if,  for  instance,  he  learned  the  correct 
answers  to  the  first  four  of  these  diagnostic  points,  operated  skilfully 
but  ignored  investigation  of  the  fifth  point  (with  reference  to  the  con- 
dition and  functional  activity  of  the  allied  organs),  it  might  very  readily 
prove  to  be  another  case  of  "successful  operation,  but  the  patient 
died;"  because  renal  involvement  with  unrecognized  suppression  of 
urine,  uremia  and  death  may  follow  on  the  heels  of  the  "successful" 
operation,  a  result  that  should  readily  be  avoided  by  attention  in  diag- 
nosis to  the  point  under  discussion,  together  with  appropriate  prepara- 
tory treatment.  Hence  it  is  evident  that  diagnosis,  to  be  efficient,  must 
be  not  only  analytical  but  comprehensive  and  inclusive. 

But  to  show  that  in  the  given  instance  of  prostatic  obstruction  it  is 
within  the  ability  of  any  practitioner  of  ordinary  skill  to  acquire  the 
information  desired  in  the  five  diagnostic  points,  it  may  be  mentioned 
that  the  first  point  is  determined  by  rectal  palpation,  the  finger  detect- 
ing whether  the  prostate  is  unduly  large,  unduly  small,  or  of  approxi- 
mately normal  size.  The  second  point  is  determined  by  the  passing 
of  a  soft-rubber  catheter  into  the  bladder  directly  after  the  patient  has 
finished  voluntary  urination,  which  shows  whether  there  is  residual 
urine  or  not ;  and  the  quantity  of  residuum  thus  obtained  is  the  answer 
to  the  third  point.  The  fourth  point  is  not  so  easily  settled,  but,  never- 
theless, should  be  settled  in  every  case  that  has  been  proved  by  the 
steps  above  mentioned  to  be  the  subject  of  prostatic  obstruction.  It  is 
most  advantageously  accomplished  by  means  of  the  cystoscope,  and 
especially  the  retrospective  lens  of  the  cystoscope,  showing  the  confor- 
mation and  character,  etc.,  of  the  vesical  neck  and  prostate.  The  fifth 
point  is  determined  by  examination  of  the  urine  and  physical  examina- 
tion of  the  heart,  together  with  the  application  of  such  functional  tests 
as  are  appropriate. 

It  is  therefore  apparent  that  if  carried  out  methodically  and  judi- 
ciously, the  essential  requirements  for  a  working  diagnosis  of  such  a 
case,  with  the  exception  of  one  point  only  (cystoscopy),  are  within  the 
ability  of  every  practitioner  of  even  ordinary  skill  and  experience;  and 
nothing  has  been  demanded  in  the  technic  that  was  either  unreasonable 
or  ultra-scientific.  As  to  the  cystoscopy,  every  town  of  self-respecting 
ambition  now  possesses  a  cystoscopist  of  sufficient  ability  to  resolve 
that  question. 


112     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  UIUXAIiY  TRACT 

Hence  the  difficulties  have  proved,  when  fairly  attacked,  neither 
insurmountable  nor  appalling.  Which  may  be  said  to  be  true,  also,  of 
diagnostic  endeavors  with  reference  to  other  diseases  of  the  urinary 
organs.  Difficulties  melt  down  and  disappear  in  the  face  of  method 
and  system,  and  repeated  endeavor  brings  success. 

PLAN  OF  INVESTIGATION. 

So  much  depends  on  method  and  system  in  developing  genito-urinary 
diagnosis  that  some  definite  plan  should  always  be  followed.  The  field 
of  investigation  being  more  or  less  limited,  it  is  feasible,  therefore,  for 
those  following  this  work  as  a  specialty  to  formulate  and  have  printed 
in  the  history  book  a  series  of  questions  relating  to  the  several  genito- 
urinary organs  or  diseases,  with  a  blank  for  the  response,  which  may  be 
filled  by  an  affirmative  or  negative  sign  for  reply.  This  markedly 
shortens  the  time  and  labor  in  getting  and  recording  the  history.  Cur- 
rent and  additional  events,  treatments,  reactions,  and  responses  may  be 
recorded  on  cards  that  are  indexed  and  filed  after  the  usual  card-index 
filing  system.  Intricate  and  time-consuming  bookkeeping  may  be 
avoided  in  this  manner  and  all  necessary  records  continued  and  kept 
indefinitely — and  always  available. 

The  diagnosis  should  be  based  on  the  following  three  kinds  of  evidence : 

1.  History  and  symptoms  of  the  case. 

2.  Physical  examination  of  the  patient. 

3.  Examination  of  the  secretions  and  excretions,  pathological  and 
physiological,  of  the  organs  in  question;  and  of  the  blood  (complement- 
fixation  tests). 

I.  History  of  the  Case. — The  questioning  should  cover  the  family 
history,  the  previous  personal  history,  and  the  history  of  the  existing 
complaint.  In  the  family  history  information  that  would  have  a  bear- 
ing on  hereditary  influences  and  stigmata  should  be  learned.  The  bale- 
ful effect  of  inherited  syphilis  is  discovered  with  surprising  frequency 
when  definite  search  is  made  for  it.  This  is  especially  true  now  that 
the  Wassermann  blood-test  has  come  into  frequent  use.  The  writer 
has  found  syphilis  to  be  the  underlying  factor  in  a  number  of  instances 
in  which  there  had  been  obstruction  at  the  vesical  neck  from  childhood 
to  manhood.3 

While  a  positive  history  of  hereditary  syphilis  might  be  of  great 
significance,  one  should  not  place  too  much  reliance  on  a  failure  to 
acknowledge  such  a  history  if  there  is  reason  to  suspect  the  contrary. 
It  is  like  the  Wassermann  blood  test  in  this  respect;  while  the  positive 
test  is  of  great  import,  the  negative  is  of  relatively  little  significance 
and  must  not  weigh  heavily  in  the  final  estimate.  Neurologic,  neurotic, 
and  other  tendencies  should  be  inquired  into  as  related  to  family 
traits. 

Previous  Personal  History. — In  both  chronic  and  acute  affections  of 
the  urinary  tract  antecedent  infections  frequently  have  a  dominant 
influence,  and  failure  to  discover  them  in  developing  the  history  may 


PLAN  OF  INVESTIGATION  113 

seriously  handicap  one's  understanding  of  the  case.  Chronic  and 
recurrent  urethral  discharges  often  are  only  exacerbations  of  uncured 
but  apparently  inactive  urethritis;  subacute  vesiculitis  may  persist  for 
years  after  active  urethral  discharge  has  ceased  to  be  an  outward  sign 
of  trouble.  The  insidious  evidences  of  urethral  stricture  come  on  when 
the  patient  has  but  a  dim  remembrance  of  his  former  infection.  Even 
at  the  risk  of  a  seeming  insistence  the  questioner  should  tactfully  learn 
about  all  such  "accidents"  and  conditions  of  the  patient's  former 
life. 

Habits  and  customs  have  a  bearing  that  is  unrealized  by  individuals, 
sometimes;  such  as  habitual  postponement  of  the  act  of  urination  until 
long  after  the  desire  has  been  felt,  either  from  occupational  causes  or 
undue  modesty.  Permanent  damage  to  the  bladder,  ureters,  and  kid- 
neys is  occasionally  the  price  of  such  heedless  practices. 

Habits  of  eating  and  drinking  may  have  a  bearing  on  obscure  cases. 

Evidences  of  rheumatism,  tuberculosis,  defective  metabolism,  dyscra- 
siiv,  loss  of  weight  or  strength,  should  be  developed  in  the  history. 

Focal  points  of  irritation  and  infection  at  distant  parts  of  the  body 
are  now  recognized  as  having  a  preeminent  bearing  on  the  urinary 
tract,  notably  the  kidneys  in  connection  with  nephritis. 

Special  inquiry  should  be  made  about  pain;  frequency  or  urgency 
in  urination;  changes  in  the  urine;  changes  in  the  stream. 

Undoubtedly  pain,  though  irksome,  is  a  great  conservator  of  the 
human  kind.  It  is  unfortunate  that  a  larger  proportion  of  genito- 
urinary maladies  are  not  ushered  in  with  pain.  A  larger  proportion 
of  sufferers  would  thereby  be  impelled  earlier  to  seek  medical  assistance. 
Many  accept  even  a  bloody  urine  complacently  for  a  long  time  just 
because  there  is  no  pain  accompanying  this  portentous  sign.  A  patient 
who  possessed  a  growing  hypernephroma  held  a  letter  of  introduction 
from  a  physician  to  the  writer  for  over  six  years  before  finally  presenting 
it;  there  was  pronounced  hematuria  all  of  that  time. 

Pain  may  be  primary  or  secondary  in  the  genito-urinary  organs. 
Originating  in  a  diseased  or  strictured  urethra,  the  irritation  may  be 
reflected  into  the  rectum,  presenting  the  whole  complaint,  so  far  as  the 
patient  knows  it,  at  that  point.  Or  ascarides  vermicularis  may  display 
their  vicious  effect  by  reflected  irritation  from  the  rectum  into  the  ure- 
thra, producing  inordinate  frequency  or  troublesome  difficulty  in  urina- 
tion. Therefore,  although  one  must  learn  what  he  can  about  pain,  in 
getting  the  history,  he  must  refrain  from  making  deductions  concerning 
it  until  physical  examination  is  able  to  set  him  right. 

Pain  in  the  back  is  ordinarily  ascribed  by  the  laity  to  "  kidney  dis- 
ease," and  on  so  slight  a  piece  of  evidence  do  they  often  take  cures  and 
courses  of  treatment  at  the  spas  of  repute.  The  profession  is  well 
a \vare  that  pain  in  the  back  seldom  has  such  a  significance,  but  the  pro- 
fession is  not  so  well  aware  of  the  fact  that  an  actual  renal  pain  is  often 
transposed  from  one  kidney  into  the  region  of  its  fellow;  and  it  often 
requires  the  more  exact  findings  of  physical  examination  to  establish 
the  real  origin  of  the  complaint. 


114     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

The  pain  of  prostatic  inflammation  is  frequently  reflected  into  the 
glans  penis;  that  of  the  ureter  into  the  cord  and  testis;  that  of  the 
vesicles  into  the  back,  the  rectum,  or  the  testis. 

Frequency  and  urgency  in  urination  are  standard  indications  of 
irritation  of  the  posterior  it  ret  lira,  not  of  the  bladder.  Inflammation  of 
the  posterior  urethra  is  in  itself  a  source  of  irritation  and  arouses  the 
undue  desire  to  urinate;  hence  undue  frequency  results.  A  healthy 
person  should  urinate  from  three  to  four  times  in  twenty-four  hours, 
and  should  not  have  to  get  up  in  the  night  for  that  purpose.  It  is 
practicable,  therefore,  to  draw  a  fairly  distinct  line  between  normal  and 
abnormal  frequency  of  urination. 

Undue  frequency  in  the  daytime  usually  means  an  irritative  or 
inflammatory  causation,  such  as  posturethritis  or  vesical  stone;  whereas, 
nocturnal  frequency  is  more  likely  to  indicate  an  obstructive  causation 
(prostatic  obstruction). 

Changes  in  the  Urine. — The  changes  in  the  urine  most  liable  to  impress 
themselves  on  the  attention  of  the  patient  relate  to  the  appearance  of 
blood,  of  pus,  or  of  precipitated  urates  or  phosphates.  Information 
based  on  the  time  of  appearance  of  any  of  these  may  be  of  great  im- 
portance, as  showing  whether  an  infection  or  disease  is  of  recent  or 
remote  origin.  Patients  have  been  able  to  establish  that  the  clouding 
of  their  urine,  for  instance  in  an  obstructive  condition  in  an  adult,  had 
existed  since  childhood,  which  would  at  once  eliminate  ordinary  pros- 
tatic hypertrophy  or  gonorrheal  infection  as  the  originators  of  the 
trouble  and  give  the  investigator  quite  a  different  view-point  from  the 
one  that  might  be  forming.  The  most  effective  use  that  can  be  made 
of  information  that  the  urine  is  bloody  is  immediately  to  start  the  train 
of  real  diagnostic  endeavor — to  put  into  motion  the  arrangements  for 
systematic  examination  of  the  whole  urinary  tract  and  not  only  trace 
the  blood  to  its  origin,  but  also  to  learn  the  reason  for  its  appearance 
in  the  urine.  Until  both  of  those  objects  are  accomplished  no  effort  should 
be  made  to  stop  the  bleeding,  unless  it  is  of  menacing  proportions.  In  the 
presence,  then,  of  hematuria,  the  first  duty  of  the  practitioner  is  one  of 
diagnosis,  not  of  treatment. 

Changes  in  the  Urinary  Stream. — Much  significance  has  been  attached 
by  some  to  the  description  of  changes  in  the  stream  as  given  by  patients, 
but  in  view  of  the  lack  of  information  or  observation  powers  in  many 
patients,  and  their  proneness  to  see  the  same  things  differently,  the 
writer  has  seldom  found  their  impressions  in  this  regard  to  be  of  much 
service.  Some  patie.nts  with  a  normal  stream  complain  that  it  has  been 
twisted  latterly ;  and  others  with  well-defined  obstruction  from  stricture 
or  congenitally  narrow  meatus,  say  that  they  have  never  had  any 
impediment  in  urination.  It  is  hardly  justifiable  to  place  reliance  in 
such  an  insecure  basis.  If,  however,  the  investigator  himself  has  the 
opportunity  to  observe  the  stream,  its  description  may  be  worth  while 
in  the  record. 

II.  Physical  Examination. — Nowhere  in  medicine  or  surgery  do 
method  and  system  count  for  more  than  they  do  in  pursuing  the 


PLAN  OF  INVESTIGATION  115 

physical  examination  of  genito-urinary  cases.  Many  times  this  will 
save  the  investigator  from  overlooking  conditions  that  have  a  vital 
bearing;  conditions  that,  without  method  and  system,  would  assuredly 
go  undiscovered.  On  a  number  of  occasions  the  writer  has  seen  crystal- 
clear  urine  passed  by  patients  which  might  have  led  to  the  inference 
that  there  could  be  no  such  thing  as  gonorrheal  infection  present;  yet 
massage  of  the  vesicles  made  directly  afterward  has  brought  out  pus 
and  gonococci,  leading  to  a  vastly  different  conclusion  and  furnishing 
the  required  revelation  for  diagnosis  and  proper  treatment. 

Physical  Examination.— Following  the  taking  of  the  history  the  uro- 
logic  patient  should  be  conducted  through  certain  prescribed  steps  of 
physical  examination,  and  without  regard  to  whether  diagnoses  have 
been  made  of  his  case  before  or  not.  The  only  exception  to  this  rule 
should  be  that  in  which  the  infectiousness  or  acuteness  of  the  trouble 
indicate  a  postponement  of  instrumentation  until  a  period  in  which  it 
will  not  in  itself  cause  injury  or  extension  of  infection. 

Physical  examination  in  genito-urinary  cases  may  be  divided  into 
general  and  local.  The  local  examination  naturally  takes  precedence 
over  the  general  from  the  nature  of  the  conditions. 

The  steps  of  local  examination  may  be  subdivided  into  (a)  those 
preceding  instrumentation,  and  (b)  those  including  instrumentation. 

Local  Examination. — (a)  Steps  Preceding  Instrumentation, — 1.  In- 
spection.— Obtain  good  exposure  of  the  external  genitals  for  complete 
inspection:  Coat  and  vest  off  and  clothing  widely  open.  Inspect  the 
external  genitals,  including  especially  the  prepuce  and  urethral  meatus 
for  pathological  secretions.  If  present,  make  smears  on  three  glass 
slides  for  microscopic  investigation :  one  for  methylene-blue  stain,  one 
for  Gram  stain,  and  a  third  for  reserve. 

2.  Have  the  patient  urinate  into  two  clean,  clear  glasses,  for  inspec- 
tion and  chemical  and  microscopic  examination:* 

Microscopic  and  Chemical  Examination. — 1.  Centrifugalize  the  two 
glasses  of  urine  for  microscopic  and  chemical  examination.  The  first 
portion  is  better  for  detecting  infecting  organisms,  pus  that  is  sparse, 
red  blood  cells,  etc.;  while  the  second  part  is  preferable  for  chemical 
examination  and  study  of  the  condition  of  the  kidneys,  as  indicated  by 
the  urine:  Albumin,  casts,  red  blood  cells,  urates,  phosphates,  specific 
gravity,  etc. 

2.  Palpation. — Prostatic  and  vesicular  palpation  and  massage. 
While  the  urine  is  undergoing  sedimentation  step  No.  2  may  be  carried 
out.  With  the  patient  well  exposed,  bending  forward  over  a  chair,  the 
hand  of  the  operator  protected  with  a  finger  cot  or  rubber  glove,  lubri- 
cated preferably  with  one  of  the  iceland  moss  or  gum  tragacanth 

*  If  from  the  interview  a  suspicion  of  urinary  tuberculosis  is  aroused,  a  specimen 
should  be  taken,  by  catheter  only,  at  a  subsequent  time  or  at  least  after  completion  of 
the  several  steps  now  being  described.  Urine  passed  voluntarily  should  never  be  used 
for  tubercle  bacillus  investigation  (except  for  guinea-pig  inoculation)  because  of  the  likeli- 
hood of  confusion  with  the  smegma  bacillus.  The  only  safe  method  is  to  exclude  the 
smegma  organisms  by  aseptic  catheterization,  either  in  males  or  females. 


116     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

preparations,  palpation  of  prostate  and  seminal  vesicles  is  carefully 
executed ;  after  which  gentle  massage  of  these  organs  is  also  carried  out. 
At  the  same  time  a  sterile  butter  platter  or  saucer  is  held  under  the 
penis  and  catches  the  drops  of  secretion  expelled  by  the  massage.  This 
also  furnishes  material  of  value  for  microscopic  examination,  both  in 
the  stained  and  unstained  ("fresh")  condition.  Gonococci  that  were 
undiscoverable  in  the  urinary  specimens  may  be  plainly  evident  in  the 
massage  specimens,  and  if  such  proves  to  be  the  case,  one  can  readily 
understand  why  it  is  worth  while  to  be  persistent  and  searching  in  such 
examinations. 

There  may  have  been  no  discharge  at  the  meatus,  in  a  given  case; 
there  may  be  nothing  of  importance  (pus,  organisms)  found  in  the  sedi- 
mented  urine  passed  after  the  inspection,  and  there  may  be  no  dripping 
into  the  butter  platter  on  massage;  and  yet  means  are  still  available 
for  gathering,  at  this  time,  gonococci-laden  secretion  from  prostate  or 
vesicles.  With  this  object  in  view,  following  the  massage  and  before 
any  instrumentation  is  undertaken,  the  patient  is  directed  to  pass 
water  again, .this  time  into  a  third  glass;  and  even  though  he  urinated 
only  a  short  while  previously  and  he  nowr  passes  but  a  fewr  drops  of 
urine,  that  amount  suffices;  for  it  brings  out  with  it  the  massage  effect 
(pus,  mucus,  leukocytes,  organisms,  spermatozoa,  etc.)  that  up  to  that 
time  had  been  retained  in  the  posterior  urethra  by  mere  lack  of  sufficient 
volume  to  flow  out.  It  has  now  been  washed  out  by  the  additional 
drops  of  urine,  and  is  at  our  disposal  for  examination  just  as  if  it  had 
been  obtained  in  the  more  usual  way.  If  the  patient  proves  unable  to 
pass  the  additional  urine  into  the  third  glass,  we  have  still  another  mode 
of  obtaining  the  desired  massage  effect:  without  a  catheter,  inject  two 
or  three  ounces  of  warm  distilled  water  into  the  bladder  and  allow  the 
patient  to  pass  it  into  the  third  glass.  It  is  then  sedimented  and  ex- 
amined as  previously  described. 

Microscopic  Examination. — See  Examination  of  the  Urine. 

Instrumentation. — (a)  Of  the  urethra;  (6)  of  the  bladder;  (c)  of  the 
ureters  and  kidney  pelves. 

I  XSTROIEXTAL   EXAMINATION    OF   THE   URETHRA. — This  Step  is  for 

chronic  cases,  not  for  acute.  It  should  be  conducted  without  pain  or 
disturbance  to  the  patient,  leaving  with  him  not  even  an  unpleasant 
memory;  and  yet  sad  experiences  with  instrumentations  may  keep 
patients  away  from  needed  medical  service  for  years  at  a  time,  so 
painful  and  shocking  sometimes  are  they. 

lineal  Anesthesia. — Fifteen  to  twenty  minims  of  5  per  cent,  alypin 
solution  properly  used  at  this  time  are  worth  their  weight  in  gold — 
giving  contentment  to  the  patient  and  blessings  to  the  doctor.  A 
rubber-tipped  anterior  urethral  syringe  is  used  to  inject  the  solution 
into  the  urethra,  a  cushion  of  air  following  the  fluid  serving  to  distend 
the  urethra  and  diffuse  the  solution  as  far  as  desired.  The  cushion  is 
made  by  injecting  the  air  with  the  same  syringe  (Fig.  89).  The  early 
burning  effect  is  soon  replaced  by  effective  local  anesthesia,  whereupon 
bulb  sounds  (the  largest  possible  size  first,  smaller  ones  next)  are  passed 


PLAN  OF  INVESTIGATION 


117 


as  far  as  the  cut-off  muscle,  to  learn  if  there  are  strictures  in  the  anterior 
urethra;  or  an  air-inflation  urethroscope  of  Mark  is  used  for  the  same 


Fio.  89. — Anesthetizing  the  anterior  urethra. 


FIG.  90. — Anesthetizing  the  posterior  urethra:     Depositor  dropping 
alypin  tablets  in  prostatic  urethra. 


purpose,  disclosing  at  the  same  time  any  erosions,  granulations,  cicatri- 
cial  deposits,  etc.,  of  chronic  urethral  processes.     A  full-sized  urethral 


118    METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

steel  sound  may  be  used  for  determining  the  permeability  of  the  poste- 
rior urethra ;  or  it  may  be  replaced  by  use  of  the  posterior  endoscope  of 
McCarthy  or  Buerger,  which  give  a  distinct  view  of  the  verumontanum 
and  its  varying  pathological  conditions.  Lastly,  the  steps  of  ordinary 
instrumentation  are  completed,  in  cases  in  which  urinary  obstruction  or 
retention  is  suspected,  by  the  passage  into  the  bladder  of  a  soft-rubber 
catheter  for  determining  the  amount,  if  any,  of  residual  urine  left  after 
the  voluntary  urination  of  a  few  minutes  before. 

(XoTE. — A  dram  or  two  of  urine  thus  found  would  be  negligible; 
whereas,  forty  ounces  would  mean  severe  obstruction,  and  the  several 
points  for  diagnosis  previously  mentioned  (page  111)  would  then  have 
to  be  solved.) 

Tubercle  Bacilli. — If  there  is  reason  to  suspect  urinary  tuberculosis, 
this  is  the  stage  at  which  investigation  with  this  in  view  should  be 
pursued. 

In  certain  cases  the  bacilli  of  tuberculosis  are  numerous  and  easily 
found  in  the  urine ;  in  other  cases  they  are  scarce  and  are  then  demon- 
strated microscopically  only  with  difficulty.  An  expedient  that  serves 
for  their  easier  detection,  to  which  attention  was  called  by  Bryson,  is 
that  of  utilizing  for  examination  the  small  amount  of  urine  (a  dram  or 
two)  that  may  be  drawn  by  catheter  shortly  after  the  patient  has  uri- 
nated voluntarily.  It  is  supposed  that  this  serves  to  collect  the  bacilli 
which  have  settled  in  the  bas-fond,  remaining  and  accumulating  there 
in  spite  of  successive  urinations. 

The  custom  of  catheterizing  after  voluntary  urination  may,  then, 
have  a  double  object:  The  determination  of  residuum,  and  the  detec- 
tion of  tubercle  bacilli.  The  importance  of  this  is  reenforced  by  reason 
of  the  belief,  long  held  by  the  writer,  that  voluntarily  passed  urine 
should  never  be  used  for  searching  for  tubercle  bacilli.  The  chance  of 
finding  the  acid-fast  smegma  bacilli  in  such  urine  is  too  great  and  of 
differentiating  them  from  tubercle  bacilli  too  precarious  to  place  reliance 
on  such  a  measure.  The  only  means  that  affords  reliability,  both  in 
men  and  women,  is  to  draw  the  urine  by  aseptic  catheterization,  avoid- 
ing the  possibility  of  including  smegma  bacilli  in  the  specimen. 

The  writer  has  personal  knowledge  of  several  instances  in  which 
failure  to  carry  out  such  precautions  led  to  erroneous  diagnoses  and 
disastrous  consequences,  reliance  having  been  placed  on  the  accuracy 
of  the  bacteriologists'  unsupported  reports. 

Summary. — The  steps  thus  presented  may  seem  from  description 
elaborate  and  ponderous;  but  they  are  much  more  so  in  description 
than  in  practice,  and  take  much  longer  in  the  telling  than  in  the  execu- 
tion. One  might  readily  elaborate  a  more  complicated  plan  of  investi- 
gation, but  the  writer  believes  the  one  submitted  to  be  simple,  definite, 
and  practicable;  and  no  one  who  endeavors  to  do  good  work  in  this 
department  can  afford  to  minimize  or  ignore  them.  Xor  should  the 
sequence  of  the  steps  be  reversed.  The  passing  of  any  instrument 
before  the  voluntary  urination  or  the  massage  would,  from  traumatism, 
superinduce  the  presence  of  blood  and  other  cellular  elements  in  the 


119 


urine  that  might  wholly  change  and  disguise  the  actual  conditions  pre- 
vailing and  lead  to  erroneous  conclusions. 

INSTRUMENTATION  OF  THE  BLADDER.  —  Sounds;  stone-searchers. 
From  time  immemorial  reliance  has  been  placed  on  sounds,  bougies,  and 
stone-searchers  for  detecting  foreign  bodies,  tumors  and  other  patho- 
logical entities  within  the  bladder.  The  sharp  contact  of  a  metal  sound 
or  searcher  with  a  stone  in  the  bladder  elicits  a  click  that  is  distinctive 
and  of  definite  value  for  diagnosis  when  attained.  But  in  a  large  pro- 
portion of  cases  in  which  vesical  stone  is  present  the  click  is  not  ob- 
tained. The  stone  may  be  coated  with  soft,  sticky  mucus  that  softens 
or  prevents  the  expected  contact;  or  it  may  be  ensconced  in  a  pocket 
under  an  overhanging  prostate  (Fig.  91),  or  in  a  diverticulum,  prevent- 
ing the  approach  of  the  searcher  within  striking  distance  of  the  stone. 

Positive  evidence  only  is  of  value  with  this  method.  But  many  a 
surgeon  and  patient,  relying  on  its  negative  evidence,  have  been  soothed 
into  false  security  against  the  presence  of  stone  and  have  failed  utterly 


FIG.  91. — Enlarged   prostate  rendering  stones  inaccessible   to   sound,   but  evident   to 
retrospective  universal  cystoscope. 

in  their  efforts  at  diagnosis.  A  diagnostic  appliance  or  method  to  be 
efficient  must  be  reliable;  one  that  gives  a  large  proportion  of  failures 
is  not  reliable  and  should  be  replaced  by  others  affording  reliability. 

Cystoscopy. — Cystoscopy  outweighs  all  other  methods  and  measures 
for  diagnosis  of  affections  of  the  bladder  and  upper  urinary  tract.  It  is 
analytical,  comprehensive,  and  convincing. 

A  discussion  of  cystoscopes  and  cystoscopic  methods  is  presented 
elsewhere,  but  it  is  deemed  appropriate  to  consider  the  logic  and  pro- 
priety of  cystoscopy  here. 

Indications  for  Cystoscopy. — The  indications  for  cystoscopy  in  con- 
nection with  disturbances  of  the  upper  urinary  tract  are  many;  the 
contra-indications  are  few. 

Cystoscopy  should  be  performed  in  practically  all  cases  of  chronic 
urinary  disturbance  in  which  no  definite  centra-indication  is  present. 

It  is  often  the  case  that  an  existing  seminal  vesiculitis  or  prostatitis 
appears  quite  sufficient  to  account  for  the  persistence  of  an  infection, 


120     METHODS  OF  DIAGXOSIS  IX  LEMOXX  OF  I'RIXARY  TRACT 

and  treatment  is  expended  solely  on  them  without  result,  until  finally, 
discouraged  by  lack  of  success  and  merely  as  an  experimental  measure, 
cystoscopy  and  ureteral  catheterization  are  carried  out,  whereupon  a 
flood  of  light  is  unexpectedly  thrown  on  the  case.  It  is  found  that  the 
infection  involves  one  or  both  pelves  of  the  kidney  as  well,  and  that 
explanation  might  never  have  been  attained  without  the  cystoscopy 
and  catheterization. 

Hematuria,  pyuria,  microbic  infection,  when  demonstrable  as  coming 
from  the  upper  or  middle  urinary  tract,  symptomatology  that  is  in- 
veterate or  is  apparently  referable  to  the  kidneys  or  ureters,  no  matter 
of  what  character,  demand  cystoscopy  with  insistence  that  should  never 
be  denied.  The  definite  indication  in  many  of  these  is  for  diagnosis 
first,  not  treatment;  and  cystoscopy,  together  with  ureteral  catheteri- 
zation and  radiography,  are  the  means  above  all  others  for  meeting  that 
indication.  Therefore,  with  chronic  or  obscure  or  unsatisfactory  con- 
ditions of  the  urinary  tract,  it  is  advisable  not  to  be  too  punctilious  in 
awaiting  the  positive  indications  for  cystoscopy,  but  rather  to  withhold 
it  only  in  the  face  of  definite  contra-indications  opposing  it. 

Contra-indications  to  Cystoscopy. — Acute  inflammatory  conditions  of 
the  urinary  tract,  together  with  exacerbations  of  chronic  inflamma- 
tions, form  contra-indications  for  cystoscopy.  This  does  not  apply  to 
anuria  from  renal  or  ureteral  stone,  which  sometimes  is  relieved  by 
ureteral  catheterization.  The  same  measure  has  been  known  to  start 
up  urinary  secretion,  for  a  time  at  least,  in  anuria  from  nephritis;  so 
that  cystoscopy  need  not  be  feared  in  these  conditions  where  there  is 
reason  to  apply  it. 

Urinary  tuberculosis  has  by  some  been  considered  a  dangerous  field 
for  cystoscopy.  It  would  more  properly  be  termed  a  dangerous  field  with- 
out cystoscopy.  The  outcome  of  neglected  urinary  tuberculosis  is  not 
only  unpromising  but  almost  assuredly  fatal.  Urinary  tuberculosis 
in  the  earlier  periods  means  infection  of  one  kidney  only  so  far  as  the 
urinary  tract  is  concerned.  In  other  words,  the  discovery  of  the  nature 
and  location  of  the  infection — clearly  the  province  of  the  cystoscope — 
is  the  vital,  pivotal  step  to  be  taken  at  a  time  when  such  a  discovery  is 
of  service — at  a  time  when  it  may  lead  directly  to  removal  of  the  origi- 
nating focus  of  infection  from  the  body  and  reclamation  to  health  of  the 
patient.  No  means  other  than  the  cystoscope  can  compare  with  it  in 
the  performing  of  this  function. 

On  the  other  hand,  experience  with  thousands  of  cases  of  urinary 
tuberculosis,  in  the  hands  of  many  operators,  has  failed  to  show  that 
cystoscopy  is  injurious.  Such  patients  are  usually  inordinately  tender 
and  demand  the  liberal  use  of  local  anesthetics,  but  they  recover  from 
the  transient  effects  of  instrumentation  quite  satisfactorily.  Some  ob- 
structive phases  of  urinary  tuberculosis  are  even  improved  by  instru- 
mentation and  local  medication. 

Prostatism. — It  is  well  known  that  prostatics  may  go  for  long  periods 
with  considerable  obstruction  and  no  infection  until  some  form  of 
instrumentation  is  undertaken;  and  whether  this  be  done  with  or  with- 


PLAN  OF  INVESTIGATION  121 

out  careful  aseptic  precautions  it  is  liable  to  precipitate  the  long-deferred 
urinary  infection  and  bring  about  conditions  more  painful  and  irritative 
tli ;in  any  that  previously  existed.  Yet  the  claim  that  a  prostatic  should 
never  be  instrumented  because  of  these  facts  would  hardly  receive 
general  support.  Like  catheterization,  cystoscopy  is  one  of  the  disa- 
greeable necessities,  temporarily  objectionable,  perhaps,  but  having  the 
ultimate  object  of  permanent  relief  and  restoration. 

As  mentioned  previously,  prostatic  obstruction  is  of  such  multi- 
farious production  that  it  cannot  be  adequately  coped  with  except  on  a 
basis  of  accurate  diagnosis. 

Contracture,  hypertrophy,  cyst  formation,  all  may  produce  obstruc- 
tion, but  do  so  in  different  ways;  and  it  requires  cystoscopic  inspection 
to  differentiate  between  them. 

It  is  as  illogical  to  expect  to  accomplish  this  object  without  cystoscopy 
as  it  would  be  to  expect  to  determine  the  amount  of  obstruction  present 
without  using  a  catheter.  And  the  use  of  either  is  as  liable  to  be  fol- 
lowed by  infection  as  the  other.  But  their  use  paves  the  way  to  re- 
covery and  is  therefore  amply  justified. 

Urethral  stricture,  prostatic  inflammation,  or  abscess  and  other 
obstructive  conditions  militate  against  or  interfere  with  the  use  of  the 
cystoscope;  but  under  such  circumstances  they  themselves  are  the  con- 
ditions demanding  attention,  and  there  is  seldom  any  need  for  cystos- 
copy in  connection  with  them.  But  if  such  a  need  were  found,  the 
obstructing  factors  could  be  attended  to  first,  opening  the  channel 
for  the  introduction  of  the  cystoscope.  A  narrow  meatus  should  be 
incised  for  the  same  purpose  when  necessary.  It  must  be  remembered, 
too,  that  there  are  small-calibered  cystoscopes  on  the  market  (No.  17  or 
18,  French)  which,  though  sacrificing  certain  features  of  the  larger 
instruments,  are  advantageous  for  such  exceptional  conditions. 

Urine  Segregation. — The  separation  of  the  urines  of  the  two  kidneys 
by  means  of  segregators  for  a  time  was  held  in  favor  by  some,  but 
further  experience  with  such  instruments  has  proved  that  they  are 
quite  unreliable  for  diagnostic  service  in  that  they  give  false  returns 
and  lead  to  erroneous  conclusions.  In  working  with  them  the  oper- 
ator is  working  in  the  dark  and  must  take  for  granted  that  such 
exacting  conditions  are  fulfilled  as  that  of  obtaining  an  effective  water- 
shed between  the  ureteral  orifices,  and  that  each  tube  of  the  instrument 
is  draining  from  its  respective  side  and  from  this  side  only.  That  the 
instrument  is  unreliable  was  proved  by  Kummel,2  who  found  that  in  a 
case  in  which  he  had  previously  removed  one  kidney,  the  only  urine 
that  flowed  came  from  the  side  on  which  the  nephrectomy  had  been 
done. 

Aside  from  its  incompetence  for  diagnosis,  the  segregator  suffers 
when  compared  from  the  therapeutic  stand-point  with  cystoscopy  and 
ureteral  catheterization.  It  offers  no  possibility  of  sounding  ureters  or 
of  administering  irrigations  to  kidney  pelves. 

URETERAL  CATHETERIZATION. — Ureteral  catheterization  is  so  closely 
associated  with  cystoscopy  that  what  has  been  said  may  well  refer,  for 


122     METHODS  OF  DIAdXOXIS  IX  7,/i.sYO.Y.s  OF  URINARY  TRACT 

the  most  part,  to  this  procedure  also.  But  when,  by  cystoscopy,  the 
pathological  condition  is  clearly  demonstrated  to  be  in  the  bladder, 
such  as  a  tumor,  stone,  simple  ulcer,  etc.,  and  there  are  no  indica- 
tions of  further  trouble  above,  ureteral  catheterization  may  be  deemed 
unnecessary. 

Some  authors  place  much  reliance  on  meatoscopy  as  a  guide  to  con- 
ditions in  the  upper  tract.  They  watch  the  urine  as  it  issues  in  jets 
from  the  ureteral  orifices,  and  inspect  the  orifices  themselves,  alleging 
that  reliable  evidence  may  thus  be  obtained  as  to  the  presence  of  pus 
or  blood  in  the  respective  urines  or  pathological  conditions  in  the 
ureters.  It  is  but  another  instance  of  positive  evidence  being  valuable 
and  negative  evidence  worthless,  or  worse. 

If  the  ureteral  orifice  displays  ulceration  or  the  funnel-shaped  de- 
pression characterizing  tuberculous  ureteral  contraction,  the  evidence 
is  of  value;  but  it  is  established  that  many  kidneys  are  tuberculous 
without  the  corresponding  ureteral  orifice  showing  any  deviation  from 
the  normal.  And  to  await  the  ureteral  demonstration  would  be 
indefinitely  postponing  required  action  and  seriously  endangering  the 
chances  of  the  patient. 

As  to  the  other  claim,  if  it  is  impossible  to  say  whether  there  are  pus 
or  blood  cells  in  a  glass  of  fairly  clear  urine  without  examining  by  the 
microscope,  one  can  readily  appreciate  how  much  greater  the  difficulty 
of  making  the  determination  by  macroscopic  observation  of  urine  while 
it  is  being  ejected  from  ureteral  orifices.  The  claim  is  preposterous 
except  for  pathological  conditions  that  are  very  pronounced.  There 
would  be  no  objection  to  the  claim  did  it  not  incline  to  mislead 
inexperienced  cystoscopists  who  may  not  realize  the  fallacies  of  the 
situation. 

It  is  advisable,  therefore,  not  to  forego  the  many  advantages  of 
ureteral  catheterization  on  too  slight  provocation.  Many  pathological 
conditions  of  the  ureter  are  not  discoverable  by  meatoscopy.  Ureteral 
strictures,  kinks  or  dilatations  may  betray  no  evidence  at  the  meatus  of 
their  existence. 

Wax-tip  Bougies. — The  wax-tip  bougies  of  Kelly  have  been  tested 
by  wide  usage  in  the  profession  but  have  not  found  favor  to  the  extent 
that  exists  with  their  illustrious  author.  That  is  probably  explainable 
by  the  difference  in  the  form  of  cystoscopes  used.  Kelly  has  never 
given  up  the  use  of  his  very  simple  pattern  of  cystoscopic  specula,  which 
he  uses  with  women  in  the  knee-chest  position.  This  permits  the  use 
of  the  wax-tip  bougies  with  more  or  less  freedom  from  danger  of  con- 
tact with  the  instruments,  thereby  producing  a  false  scratch.  Most 
practitioners  now  use  one  of  the  several  forms  of  lens  cystoscopes  on 
the  market.  With  these  it  is  difficult  or  impossible  to  prevent  the 
scratching  of  the  tip  by  the  cystoscope  itself,  and  thus  casting  doubt 
and  confusion  on  the  findings. 

Obstructions  in  Ureteral  Catheterization. — Obstruction  to  the  passage 
of  a  ureteral  catheter  may  occur  either  in  a  healthy  or  a  diseased  ureter. 
The  axis  of  the  channel  may  be  such  that  the  catheter  impinges  against 


RADIOGRAPHY  IN  GENITO-URINARY  DIAGNOSIS          123 

the  wall  and  hangs  there  until  dislodged  by  a  twist  or  movement  that 
enables  the  catheter  to  follow  the  curve  of  the  channel,  when  it  may 
pass  easily.  In  other  instances  the  presence  of  the  catheter  excites 
spasmodic  contractions  for  a  time  of  the  muscles  of  the  ureter,  which 
clamping  down  on  the  catheter  effectually  oppose  its  passage  until  the 
spasm  is  relieved,  when  the  catheter  passes  promptly  and  without 
further  difficulty.  Obstructed  ureteral  catheterization,  therefore,  does 
not  always  point  to  a  pathological  condition. 

Organic  pathological  conditions,  such  as  narrow  ureteral  meatus  or 
stricture  of  the  ureter,  impacted  calculus,  kink,  or  an  anomalous  vessel 
crossing  the  ureter,  may  obstruct  the  passage  of  a  ureteral  catheter, 
and  when  met  with  must  be  differentiated  by  the  various  methods  dis- 
cussed. Through  the  influence  of  a  strictured  ureter  it  often  happens 
that  from  the  resulting  or  coincident  pelvic  infection  mucopus  plugs 
cause  colics,  persisting  pain,  and  backward  pressure  by  coming  in 
contact  with  and  plugging  up  the  narrowed  orifice  of  such  a  constriction. 
The  author  has  seen  prolonged  invalidism  result  therefrom,  relieved 
promptly  and  permanently  by  widening  the  contraction  to  physiological 
proportions. 

Lack  of  Drainage  after  Ureteral  Catheterization. — It  occasionally 
happens  that  after  an  especially  irksome  and  difficult  essay  at  cathe- 
terization success  is  finally  attained  and  the  fruits  of  victory  are  natu- 
rally expected,  but  none  appear.  In  other  words,  the  urine  does  not 
flow  through  the  catheters,  notwithstanding  their  introduction  well  up 
to  the  kidney  pelves.  Such  a  disappointing  failure  may  result  from 
any  one  of  several  causes.  The  catheter  itself  may  be  stopped  up,  or 
it  may  be  too  high  in  the  pelvis,  thus  failing  to  locate  the  eye  of  the 
catheter  where  it  can  draw  the  contents  by  siphonage  or  otherwise. 
A  little  mucopus  plug  caught  in  the  eye  of  the  catheter  may  close  the 
outlet  and  defeat  drainage  for  the  time  being.  Another  prolific  cause 
for  lack  of  drainage  is  the  temporary  discontinuance  of  renal  activity 
in  the  presence  of  catheters  in  the  ureters,  one  or  both.  The  resulting 
"shock"  to  the  kidneys  seems  to  superinduce  a  temporary  anuria  or 
oliguria.  The  drinking  of  a  glass  of  water  usually  restores  activity 
and  the  expected  drainage. 


RADIOGRAPHY.     ITS  POSITION  IN  GENITO-URINARY  DIAGNOSIS. 

Value  of  Radiography. — In  connection  with  cystoscopy  and  ureteral 
catheterization,  radiography  is  invaluable  for  genito-urinary  diagnosis. 
It  has  helped  tremendously  to  bring  urinary  diagnosis  to  its  present 
satisfactory  state.  But  it  must  not  be  considered  as  all-sufficient  or 
free  from  liability  to  err.  It  indulges  in  errors  both  of  commission  and 
of  omission.  Its  shadows  must  be  attested  and  controlled  lest  they 
betray  us  into  diagnosing  stones  that  are  not  present,  and  its  occasional 
failure  to  delineate  a  shadow  where  one  ought  to  be  is  one  of  its  lament- 
able shortcomings. 


124     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  CRINARY  TRACT 

Nevertheless,  when  these  failings  are  met  and  controlled  by  appro- 
priate action,  radiography  becomes  the  wheel-horse  of  service  men- 
tioned. 

The  corollary  to  the  above  is  that  radiography  in  urology  should  not 
be  relied  on  without  the  control  of  cystoscopy  and  possibly  ureteral 
catheterization.  It  may  also  be  admitted  that  for  diagnosis  of  stone 
in  the  upper  tract,  cystoscopy  and  ureteral  catheterization  should  not 
be  relied  on  without  the  control  of  radiography.  In  other  words,  they 
are  mutually  interdependent  and  should  be  utilized  together.  It  is 
mere  waste  of  time  to  speculate  on  which  is  the  more  important  of  the 
two. 

Radiography  in  Diseases  of  the  Middle  Urinary  Tract. — For  diseases 
of  this  part  of  the  tract,  radiography  is  less  important,  though  not 
without  marked  value  in  certain  conditions.  It  serves  well  in  the 
detection  of  stone  in  the  prostate.  With  oxygen  gas  distending  the 
bladder  Kelly  has  taken  good  negatives,  showing  the  size  and  con- 
formation of  enlarged  prostates.  Used  with  collargol  distention  of  the 
bladder,  radiography  dilineates  diverticula  of  that  organ,  and  shows 
the  shape  and  size  of  the  bladder  to  advantage. 

The  size  of  a  vesical  tumor  is  often  made  appreciable  by  the  same 
means,  but  without  the  use  of  the  collargol.  Kelly  used  bismuth 
suspension  in  tragacanth,  and  later,  a  suspension  of  argentide,  for  this 
purpose.  Information  regarding  the  size,  number,  and  location  of 
vesical  stones  and  foreign  bodies  is  afforded. 

Radiography  in  Diseases  of  the  Upper  Urinary  Tract. — It  is  especially 
in  this  part  of  the  tract  that  the  supreme  advantages  of  radiography  are 
made  manifest.  It  is  found  to  be  most  serviceable  and  reliable  when 
used  in  connection  with  such  control  appliances  as  radiograph  catheters 
(opaque  to  .r-rays),  ureteral  sounds,  or  the  injection  of  colloidal  silver 
solutions  (ureteropyelography) .  While  certain  precautions  are  re- 
quired to  avoid  accident  or  injury  to  the  kidneys  in  this  work,  it  may  be 
said  that  these  are  easily  carried  out,  and,  with  them  in  effect,  the  pro- 
cedures are  safe. 

Dangers  of  Pyelography. — There  are  certain  elements  of  danger  in 
injecting  the  renal  pelves  with  collargol  solution  in  that  it  has  been 
shown  that  even  under  very  moderate  pressure  the  solution  passes  up 
the  urinary  tubules  and  permeates  the  kidney  tissues  to  make  infarcts1 
and  infiltrations  that  have  proved  highly  injurious  or  even  fatal. 

In  applying  this  method  stringent  precautions  must  be  taken  to 
obviate  this  fault.  It  should  not  be  applied  in  a  case  in  which  drainage 
from  the  pelvis  is  seriously  interfered  with  unless  provision  is  made  for 
prompt  artificial  evacuation  (drainage  by  ureteral  catheter,  for  in- 
stance). The  injection  should  be  made,  not  with  a  piston-syringe, 
which  may  prove  too  forcible  in  its  effect,  but  by  a  simple  hydrostatic 
apparatus  such  as  that  of  Thomas. 

The  necessity  for  using  radiograph  catheters  is  brought  about  by  the 
fact  that  calcified  glands  or  phleboliths  in  the  abdomen  or  pelvis  often 
give  shadows  to  .r-rays  that  resemble  those  of  ureteral  stones,  and  it  is 


RADIOGRAPHY  IN  GEN  I  TO-URINARY  DIAGNOSIS  125 

desirable  to  provide  some  method  of  differentiating  between  them. 
The  opaque  catheter  in  the  ureter  shows  the  exact  line  of  the  ureter, 
a  shadow  widely  separated  from  that  line  is  at  once  recognized  as 
having  no  relation  to  the  ureter  or  ureteral  stone.  A  shadow  in  the 
line  of  the  catheter  shadow  is  differentiated  by  filling  the  ureter  with 
collargol  solution  and  then  making  the  exposure  (Braasch).  If  it  is  a 
ureteral  stone  shadow,  a  distinct  difference  in  the  caliber  of  the  ureter 
above  and  below  the  shadow  is  seen;  the  ureter  is  relatively  dilated 
iihare  the  site  of  the  stone.  Whereas,  if  it  is  only  a  phlebolith  shadow, 
there  is  no  difference  in  ureteral  caliber  above  and  below  the  shadow, 
as  indicated  by  the  pyelogram.  Another  means  of  differentiation  is  that 
of  stereoscopic  radiogram,  also  with  the  opaque  bougie  in  the  ureter 
(Kelly) .  The  stereoscopic  view  removes  the  shadow  from  the  plane  of 
the  ureter,  either  forward  or  backward,  showing  it  is  not  in  the  ureter. 
It  is  safe  not  to  put  too  much  faith  in  the  ability  of  the  radiologist  to 
make  the  differentiation  by  the  characteristics  of  the  shadow  itself. 
This  has  proved  fallacious  in  many  instances.  Nevertheless,  certain 
characteristic  differences  in  shadows  have  been  noted,  as  pointed  out 
by  Fenwick.  Shadows  that  are  clean  cut,  round  and  grouped  near  the 
outer  or  ischial  portion  of  the  open  pelvic  space  in  an  ar-ray  picture  are 
likely  to  be  those  of  phleboliths,  while  the  ureteral  stone  shadows  are 
inclined  to  be  oval,  with  the  long  axis  in  the  line  of  the  ureter,  and 
located  near  the  median  line  of  the  body. 

Capacity  of  the  Kidney  Pelvis. — The  question  is  important  for  differ- 
entiation between  a  normal  pelvis,  a  dilated  one,  and  hydronephrosis 
or  pyonephrosis.  Injecting  fluid  through  a  ureteral  catheter  to  the 
point  of  exciting  pain,  Kelly  allows  8  c.c.  capacity  as  the  normal  maxi- 
mum; whereas  Braasch  considers  15  c.c.  as  compatible  with  physio- 
logical capacity. 

Indications  for  Radiography  of  the  Upper  Urinary  Tract. — Radiography 
and  pyelography  are  applicable  to  cases  in  which  there  is  ground  for 
suspecting  stone,  stricture,  kink,  obstruction  of  any  sort,  or  dilata- 
tion at  any  point  in  the  ureter;  or  duplicated  ureter;  hydronephrosis 
or  pyonephrosis;  calculus,  benign  or  malignant  tumor,  tuberculosis  or 
abscess  formation  in  connection  with  the  kidney.  Modern  radiograms 
made  with  "soft"  tubes  are  capable  of  showing  shadows  of  abscess 
pockets,  tuberculous  and  like  conditions,  that  are  of  much  service  when 
correctly  interpreted. 

Interpretation  of  Radiograms. — It  must  not  be  thought  that  this  is  an 
easy  matter  or  one  requiring  only  indifferent  ability.  Much  experience 
and  refined  judgment  are  really  necessary;  and  these  must  be  backed 
with  the  repeated  testings  and  the  various  methods  of  control 
available. 

Preparation  of  the  Patient. — In  anticipation  of  radiography  the  patient 
should  be  prepared  so  as  to  eliminate  extraneous  factors  as  much  as 
possible.  The  bowels  should  be  emptied,  including  flatus,  by  a  brisk 
cathartic;  and  a  light  diet  should  be  observed  for  a  day  or  two  before- 
hand, when  permissible. 


126     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

Technic  and  Mode  of  X-ray  Examination.— This  will  be  considered 
elsewhere.  It  may  be  remarked,  however,  that,  as  with  ureteral  cathe- 
terization,  if  one  is  guided  solely  by  the  symptoms  and  takes  a  radio- 
gram only  on  the  side  complained  of,  one  is  liable  to  overlook  evidence  of 
great  value  that  may  exist  on  the  opposite  side.  Unless  the  opposite 
side  has  been  definitely  excluded  by  ureteral  catheterization  as  a  source 
of  trouble,  it  is  advisable  to  take  both  the  kidney  and  ureter  of  that 
side — always  remembering  that  a  shadow  without  the  control  of  the 
radiograph  catheter  merely  indicates  the  taking  of  another  radiogram 
with  such  a  catheter  in  place. 

Kelly  suggests  that  it  is  well  to  take  a  verifying  plate  a  day  or  two 
following  the  positive  finding  or  before  a  contemplated  operation  for 
stone;  not  only  for  verification  but  also  for  indicating  a  change  in  the 
position  of  a  stone. 

Stereoscopic  Radiography. — This  refinement  of  .r-ray  photography 
serves  to  place  the  shadow  of.  a  stone  or  foreign  body  with  reference  to 
the  horizontal  planes  of  the  body.  Used  in  connection  with  a  radio- 
graph catheter  in  the  ureter  it  gives  an  attractive  elucidation  of  con- 
ditions not  otherwise  rendered. 

FUNCTIONAL  TESTS. 

The  integrity  of  the  kidneys  is  universally  recognized  as  being  of 
great  moment  in  its  bearing  on  the  risk  involved  by  a  given  surgical 
operation.  But  this  risk  relates  not  so  much  to  the  anatomicopatho- 
logical  condition  of  the  kidneys  as  to  their  functional  activity.  Conse- 
quently, while  the  information  obtained  by  chemical  and  microscopic 
tests  of  urine  is  valuable,  it  is  not  the  kind  of  information  that  is  most 
useful  in  the  case  at  hand.  The  pathological  condition  does  not  always 
parallel  the  functional  activity.  Some  kidneys  badly  degenerated  give 
urine  that  shows  good  excretion  by  reason  of  adequate  compensation; 
while  others  apparently  little  involved  may  give  urine  very  inferior  in 
quantity  and  quality.  Individuals  with  albumin  and  casts  in  their 
urine  have  been  known  to  live  for  many  years  without  apparent  progress 
in  the  renal  condition  or  decrease  in  the  kidney  activity.  But  the 
menace  comes  when  the  function  is  inefficient — even  in  the  face  of  a 
sufficient  quantity  of  urine  and  of  fair  quality.  So  insignificant  an 
operation  as  a  urethral  catheterization  may  disturb  the  equilibrium 
that  has  existed,  and  be  followed  by  suppression  of  urine  and  death. 
Such  sequences  have  occurred  even  where  the  volume  and  quality  of 
urine  seemed  to  be  satisfactory. 

Variability  of  Renal  Function. — This  is  marked  in  both  health 
and  disease;  and  depends  on  many  influences.  A  glass  of  beer  in  a 
healthy  person  may  double  or  quadruple  the  urinary  output  in  the 
space  of  a  few  minutes.  Functional  activity  that  is  lessened  through 
disease  may  be  restored  by  removal  of  the  disease  (acute  nephritis)  or 
its  cause  (a  prostatic  obstruction).  Therefore  the  estimate  should 
include  not  only  the  actual  renal  activity  but  also  the  potential  capa- 


FUNCTIONAL  TESTS  127 

bilities  of  the  kidneys  under  better  or  worse  conditions — for  instance,  in 
the  face  of  an  operation,  especially  a  nephrectomy. 

With  the  exception  of  hippuric  acid  the  kidneys  do  not  manufacture 
any  of  the  waste  products  that  issue  from  them.  They  simply  extract 
them  from  the  blood.  It  is  the  measure  of  this  faculty  of  extraction 
that  is  desired.  If  the  renal  function  is  adequate,  the  waste  products 
are  excreted  sufficiently  and  the  blood  is  kept  in  its  proper  and  healthy 
condition.  If  kidney  activity  is  below  the  requirements  of  the  individual, 
such  products  accumulate  unduly  in  the  blood  or  tissues  of  the  body. 

To  determine  whether  this  function  is  being  properly  attended  to, 
it  would  seem  proper  to  investigate  either  (a)  the  state  of  the  blood, 
with  reference  to  retention  of  waste  products  in  it,  or  (6)  the  product 
of  the  kidneys  (the  urine),  with  reference  to  completeness  of  excretion. 
These  tests  would  resolve  themselves,  then  into  (a)  tests  of  retention 
and  (6)  tests  of  excretion  (Hinman). 

The  tests  of  retention  (cryoscopy  of  the  blood,  electrical  conduc- 
tivity) have  so  far  not  proved  their  efficiency  or  reliability.  The 
nitrogen  content  of  the  blood  has  been  found  by  some  (Widal,  Folin, 
Ovisannikova)  to  have  mucji  prognostic  significance.  When  the  blood 
urea,  in  a  case  of  nephritis,  rises  to  one  or  two  grams  per  liter,  the 
prognosis  is  considered  a  grave  one;  if  above  three  grams,  impending 
uremia  and  dissolution  are  expected.  The  normal  limits  are  from  0.1 
to  0.55  gram  per  liter. 

The  tests  of  excretion  have  found  most  favor  because  of  their  greater 
convenience  and  reliability.  Apparently  realizing  the  supreme  value 
that  would  attach  to  the  finding  of  an  efficient  test  of  tbis  kind,  students 
of  the  subject  have  submitted  many  different  tests  during  the  past 
decade.  They  have  aimed  at  measuring  the  rapidity  and  completeness 
with  which  in  a  given  case  the  test  drugs  were  eliminated  through  the 
kidneys,  and  the  relative  activity  of  the  two  kidneys  as  tested  sepa- 
rately ;  this,  mainly  to  learn  whether,  if  the  diseased  kidney  were  oper- 
ated on  or  removed,  the  remaining  one  could  fulfill  the  requirements  of 
elimination  and  sustain  life. 

Endeavors  at  gauging  functional  activity  or  insufficiency  by  measur- 
ing the  amount  of  the  physiological  waste  products  of  the  urine  have 
proved  unreliable.  The  chlorides,  the  phosphates,  uric  acid,  the  urates, 
urea,  the  total  solids,  etc.,  vary  so  much  in  health  and  the  variations 
depend  on  such  multifarious  causes  that  they  cannot  be  interpreted  as 
having  any  relationship  to  operative  risk  or  renal  potentiality.  The 
same  thing  may  be  said  for  the  total  quantity  of  urine.  While  it  is 
of  material  value  and  definitely  advisable  to  make  use  of  these  (urea, 
total  solids,  total  quantity  of  urine,  etc.)  there  yet  remains  something 
to  be  desired  for  determining  functional  activity. 

For  reckoning  permeability,  the  following  products  have  been  found 
of  most  service:  Phloridzin,  methylene  blue,  indigo-carmin,  phenol- 
sulphonephthalein  (reduced  for  convenience  to  "phthalein"). 

Phloridzin. — The  discovery  by  von  Mehring  that  phloridzin  renders 
the  kidney  very  permeable  to  sugar  led  to  its  use  as  a  test  of  renal  func- 


128     METHODS  OF  DIA(;\OXIS  L\  LESIOX*  Of  L'RIXARY  TRACT 

tional  activity,  and  it  seemed  at  first  to  promise  much  in  this  respect; 
but  it  was  found  that  there  was  occasionally  no  elimination  of  sugar  at 
all  in  perfectly  healthy  kidneys,  while  in  others  with  only  slight  deteri- 
oration the  test  would  apparently  indicate  serious  degeneration.  It 
has  therefore  not  held  the  position  at  first  hoped  for  it. 

The  manner  of  using  the  phloridzin  test  is  as  follows :  An  injection  of 
0.01  to  0.05  gm.  of  the  drug  in  aqueous  solution  is  made  subcutane- 
ously,  intramuscularly  or  intravenously,  the  solution  being  freshly 
prepared  and  slightly  alkalinized  with  bicarbonate  of  soda,  which 
favors  complete  solution.  After  ten  minutes  the  urine  is  tested  every 
minute  with  Fehling's  solution  until  the  appearance  of  the  sugar  is 
indicated  in  the  usual  way.  Fifteen-  or  thirty-minute  estimates  of  the 
output  are  then  recorded.  The  sugar  should  make  its  appearance  in 
from  ten  to  fifteen  minutes  with  normal  conditions;  reaches  its  maxi- 
mum in  one  hour  and  gradually  disappears  in  from  two  to  three  hours, 
with  a  total  excretion  in  that  time  of  one  or  two  grams  (Geraghty  and 
Rowntree). 

Indigo-carmin,  methylene  blue,  and  other  anilin  dyes  have  been 
praised  in  this  light.  The  first  is  used  by  intramuscular  injection  of 
20  c.c.  of  a  0.4  per  cent,  solution  freshly  prepared  in  sterile  distilled 
water  at  room  temperature  (warmed  before  using).  In  about  nine 
to  twelve  minutes  after  the  injection  is  made,  a  greenish-blue  tinge 
appears  in  the  urine,  with  normal  kidneys,  and  continues  until  about 
25  per  cent,  of  the  injected  drug  has  returned  through  the  kidneys.  But 
only  10  to  12  per  cent,  returns  in  an  hour,  and  it  continues  showing 
for  the  next  day  or  two. 

B.  A.  Thomas9  puts  much  faith  in  this  test,  but  in  addition  to 
marking  the  promptitude  of  its  appearance  after  injection,  be  seeks, 
as  he  terms  it,  the  index  Cff  elimination  of  the  drug;  that  is,  he  divides 
the  quantity  of  indigo-carmin  eliminated  during  the  first  hour  by  the 
quantity  excreted  during  the  third  hour  after  injection.  He  found  that 
the  index  for  normal  individuals  in  a  series  of  cases  averaged  5.1.  If 
the  amount  eliminated  during  the  third  hour  equals  or  exceeds  that 
excreted  the  first  hour,  the  patient's  kidney  function  centra-indicates 
serious  operative  intervention. 

The  conclusions  are  based  on  the  theory  that  disease  of  the  renal 
parenchyma  delays  the  onset  of  elimination  and  diminishes  the  early 
output  as  well,  while  the  duration  of  excretion  is  prolonged;  it  there- 
fore seemed  to  the  author  that  the  relative  excretion  for  the  first  and 
third  hours  was  of  greater  value  than  'the  mere  quantitive  output  for 
the  first  two  hours.  Thomas  considers  this  to  be  the  safest  guide  to 
renal  functionation  of  all  the  tests  that  have  been  proposed. 

Methylene  blue  has  been  held  in  much  the  same  esteem  by  its  spon- 
sors, Kutner  and  Casper,  and  later  Achard.  But  by  others  it  is  rated 
of  inferior  merit.  Investigation  showed  that  in  certain  forms  of  neph- 
ritis there  was  none  of  the  expected  delay  in  the  appearance  of  the  green 
tint  (normally  nine  to  twelve  minutes)  after  injection  nor  any  inter- 
ference with  the  rapidity  of  its  excretion;  while  in  some  normal  cases 


FUNCTIONAL  TESTS  129 

the  drug  did  not  appear  in  the  urine  at  all  after  the  injection.  Its 
unreliability  condemned  it. 

Methylene  blue  is  given  by  intra-muscular  injection,  fifteen  minims 
of  a  5  per  cent,  aqueous  solution  being  used.  Fifty  per  cent,  of  the 
drug  comes  back  in  the  urine;  the  remainder  is  supposed  to  be  con- 
verted in  the  body.  The  blue-green  color  should  make  its  appearance 
in  the  urine  within  twenty  to  thirty  minutes  after  injection,  and  may 
continue  to  show  for  one  or  two  days  thereafter.  In  some  cases  of 
nephritis  it  has  been  observed  as  persisting  for  fifteen  days.  In  inter- 
stitial nephritis  its  initial  appearance  may  be  delayed  for  five  or  six 
hours,  whereas  in  parenchymatous  nephritis  there  may  be  no  marked 
delay  (Albarran;  Bond;  Hinman). 

These  instances  serve  to  indicate  the  difficulty  of  finding  a  functional 
renal  test  that  furnishes  accuracy,  reliability  and  innocuousness. 
Nevertheless  one  closely  approaching  the  fulfillment  of  these  exacting 
requirements  has  been  found. 

Phenolsulphonephthalein.  This  agent  ("phthalein,"  for  conveni- 
ence) possesses  certain  properties  and  reactions,  as  described  by  Ger- 
aghty  and  Rowntree  (1910-1912),  that  make  it  more  nearly  ideal  than 
anything  heretofore  proposed.  It  is  innocuous,  even  in  large  doses. 
It  is  secreted  entirely  by  the  kidneys  and,  in  health,  with  punctilious 
uniformity,  both  as  to  time  of  appearance  and  rate  of  excretion.  And 
this  rapidity  is  so  great  that  within  two  hours  after  it  has  made  its 
appearance  in  the  urine  (beginning  ten  minutes  after  injection)  from 
00  to  85  per  cent,  of  the  drug  passes  out  in  the  urine.  This  fact  is 
doubly  valuable,  both  for  an  estimate  of  the  total  function  of  the  two 
kidneys,  and  for  determining  the  relative  functioning  power  of  the 
two  organs. 

The  rapidity  of  elimination  shows  variations  dependent  on  the 
method  and  location  of  introduction  of  the  dose.  The  response  is 
slowest  and  least  certain  after  subcutaneous  injection;  more  prompt 
with  intramuscular  injection  and  most  prompt  with  intravenous  use. 
It  is  therefore  advisable  to  use  either  the  intramuscular  or  intra- 
venous. The  latter  is  particularly  useful  in  connection  writh  ureteral 
catheter  drainage,  the  test  being  completed  in  fifteen  minutes  and 
permitting  a  snorter  retention  of  the  catheters  in  the  sensitive 
ureters. 

While  it  is  practicable  to  determine  the  promptitude  of  appearance 
of  phthalein  in  the  urine  after  injection,  it  is  not  essential,  and  this 
is  not  nearly  so  important  as  the  measurement  of  the  amount  of  the 
drug  excreted  in  the  first  and  the  second  hour  taken  separately.  After 
intramuscular  use,  the  time  of  appearance  is  from  five  to  ten  minutes ; 
the  output  for  the  first  hour  from  40  to  60  per  cent.;  for  the  second 
hour,  20  to  25  per  cent,  (making  from  60  to  85  per  cent,  for  the  two 
hours) .  When  administered  intravenously  in  connection  with  ureteral 
catheterization,  it  appears  in  from  two  to  eight  minutes.  The  collection 
of  urine  for  the  fifteen-minute  or  half-hour  period  should  begin  with  the 
appearance  of  color  in  either  urine.  To  make  the  drug  visible,  a  few 
M  u  i — 9 


130     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

drops  of  sodium  hydrate  solution  are  placed  in  the  test-tubes  or  vessels 
intended  for  receiving  the  urine  drainage.  Then,  at  the  moment  when 
excretion  begins,  a  pinkish  tinge  appears,  merging  into  a  definite 
Bordeaux  red  by  the  additional  flow. 

In  order  that  there  may  be  no  inhibition  of  urinary  secretion  from  the 
presence  of  the  ureteral  catheters,  it  is  advisable  to  have  the  patient 
drink  one  or  two  glasses  of  water  before  the  beginning  of  the  test. 

Schmidt  and  Kretchmer7  advise  the  collection  of  urine  for  three 
successive  hours,  believing  that  the  excretion  for  each  of  three  hours  of 
the  same  amounts  of  phthalein  indicates  that  the  kidneys  are  working 
at  top  speed  all  the  tune  because  they  are  badly  damaged. 

Relative  Functional  Activity. — Where  the  quantity  of  urine,  merely,  is 
measured  and  the  collection  is  made  for  ten  minutes  only,  there  may 
be  a  marked  difference  in  the  amount  excreted  by  two  healthy  kidneys. 
But  if  the  time  of  collection  be  prolonged  for  an  hour  or  two,  or  per- 
haps if  repeated  at  another  time,  this  discrepancy  is  made  up  and  the 
account  balanced. 

Excretion  of  phthalein,  however,  does  not  depend  on  the  quantity 
of  fluid  excreted,  whether  large  or  small,  and  its  relative  findings  are 
positive  indications  of  functional  activity,  whether  taken  at  long  or 
short  intervals.  This,  indeed,  is  one  of  the  vital  advantages  of  the 
test,  making  it  both  useful  and  reliable. 

Technic  of  Applying  the  Phthalein  Test.— Intramuscular. — Ampules 
containing  about  20  minims  of  standard  solution  of  Phenolsulphone- 
phthalein  are  supplied  by  Hynson  &  "\Yestcott,  of  Baltimore,  Md. 
Exactly  one  cubic  centimeter  is  injected  by  hypodermic  syringe  deeply 
into  the  gluteus  or  any  muscle  of  the  lumbar  region,  the  time  of  injec- 
tion being  noted.  A  soft-rubber  catheter  in  the  bladder  drains  the 
urine  as  it  enters  that  organ  from  the  kidneys.  The  drainage  is  caught 
in  a  white  enamel  vessel  containing  a  few  drops  of  sodium  hydrate 
solution,  which  renders  the  phthalein  visible  on  the  instant  of  its 
arrival  in  the  vessel.  The  appearance  of  the  pink  color  marks  the 
beginning  of  the  first  hour  of  the  quantitative  phthalein  estimate.  The 
catheter  is  withdrawn  and  is  reinserted  an  hour  from  that  time  for 
obtaining  the  first  hour's  specimen.  Sixty  minutes  later  the  second 
hour's  specimen  is  obtained  in  the  same  way  (unless  the  patient  can  be 
depended  on  for  completely  emptying  his  bladder  by  voluntary  urina- 
tion, default  of  which  vitiates  the  result).  The  phthalein  percentage 
of  the  two  hours'  excretion  is  then  determined  by  adding  to  each  speci- 
men respectively  enough  water  to  make  1000  c.c.;  placing  a  few  cubic 
centimeters  of  this  diluted  specimen  in  the  cup  of  the  colorimeter  of 
DuBoscq,  which  by  comparison  with  a  standard  solution  at  once  gives 
the  required  percentage.  The  same  is  then  done  with  the  diluted 
specimen  from  the  second  hour's  excretion  and  its  reading  recorded. 
When  ureteral  catheterization  is  employed  for  determining  the  relative 
functional  activity  of  the  two  kidneys,  the  intravenous  method  should 
be  used  and  the  time  lessened  as  previously  suggested.  Fifteen  minutes 
(one-fourth  of  an  hour)  is  the  customary  period  used,  and  its  result 


EXAMINATION  OF  THE   URINE  131 

is  multiplied  by  four  for  the  full  hour.  This  represents  the  output 
of  each  kidney,  which,  added  together,  gives  the  output  of  both  kid- 
neys. In  the  first  fifteen  minutes  a  normal  kidney  should  put  out  half 
of  about  30,  or  15  per  cent.  (G.  G.  Smith).  If  one  kidney  is  diseased 
and  putting  out  less  than  the  normal  (less  than  15  per  cent.),  the  other 
may  be  compensating  and  putting  out  more  than  15  per  cent.  Hence 
the  value  of  making  the  comparative  functional  test  by  ureteral  cath- 
eterization. 

In  women  the  average  output  is  slightly  lower  than  in  men. 

In  summing  up,  it  may  be  said  that  no  one  test  should  be  relied  on 
as  all-sufficient,  but  that  a  working  combination  of  two  or  three  should 
be  utilized.  The  daily  output  of  urine-urea  and  solids,  the  quantity 
of  urine,  together  with  phthalein  estimate,  repeated  as  necessary,  should 
be  prominent  among  the  factors  determining  the  question  of  operation 
and  prognosis. 

According  to  Cabot,  the  stability  of  renal  functionation,  established 
by  successive  tests,  is  of  greater  moment  than  a  high  functional  per- 
centage. Patients  who  under  strains  of  exercise,  changes  of  diets  or 
alterations  in  quantity  of  water  vary  markedly  in  their  renal  output 
are  less  favorably  considered  than  those  having  a  lower  index  which  is 
well  maintained  under  these  influences. 


EXAMINATION  OF  THE  URINE. 

While  the  conventional  steps  of  urine  examination  will  not  be  con- 
sidered here,  it  may  be  profitable  to  express  some  thoughts  on  the 
subject  that  clinical  experience  has  indicated  as  of  frequent  and  prac- 
tical importance. 

Examination  of  the  urine  may  be  of  incalculable  service  in  tracing 
the  location  and  nature  of  a  genito-urinary  affection.  But  it  must  be 
made  understandingly  and  not  in  the  stilted,  routine  fashion  ordinarily 
carried  out.  Many  think  that  if  they  have  learned  whether  a  patient's 
urine  contains  albumin  or  not  their  full  obligation  in  that  direction 
has  been  discharged.  As  a  matter  of  fact,  such  a  return  may  offer  no 
enlightenment  on  the  case,  one  way  or  another.  Aside  from  the  evidence 
on  renal  functional  capability,  considered  elsewhere,  the  pertinent 
questions  to  be  answered  are,  what  pathological  elements  does  the 
urine  contain;  and  from  wrhence  do  they  come?  Eminently  practical 
questions,  both,  and  answerable  by  definite  methods  of  investigation. 
Volumes  have  been  written  in  the  endeavor  to  make  the  source  of 
urinary  disturbance  recognizable  by  means  of  the  particular  shape  or 
other  characteristics  of  epithelia  formed  in  the  urine;  that  caudate 
epithelia  mean  pyelitis,  etc.  To  the  mind  of  the  writer  this  is  mere 
waste  of  time ;  and  illusory.  More  exact  methods  are  those  which  trace 
the  epithelia  or  pus  cells  or  other  pathological  findings  to  their  source 
by  the  definite  means  of  cystoscopy,  ureteral  catheterization  and  radi- 
ography. Mark  Twain  said  that  when  he  dined  at  a  boarding  house  he 
always  called  for  hash  because  he  wanted  to  know  what  he  was  eating. 


132     METHODS  OF  DIAGNOSIS  L\  LESIONS  OF  URINARY  TRACT 

In  this  work  one  wants  to  know  one's  evidence,  putting  doubt  and 
speculation  as  far  behind  one  as  possible.  One  should  never  assume 
an  ability  to  name  the  contents  of  urine  by  viewing  it  macroscopically; 
yet  this  assumption  is  practised  habitually  by  some.  Many  a  speci- 
men of  urine  looks  limpid  clear  and  innocent,  yet  contains  blood 
cells,  pus  corpuscles  or  tubercle  bacilli;  and  these  spell  pathological 
conditions. 

Cloudy  Urine. — The  clouding  of  urine,  apparent  to  the  naked  eye  as 
viewed  in  the  urine  glasses,  may  come  from  the  admixture  in  it  of 
precipitated  urates  or  phosphates,  of  spermatozoa,  pus  cells,  blood 
cells,  epithelia,  bacteria,  parasites  of  various  sorts,  and  foreign  material 
(dirt),  and  crystalline  formations. 

It  should  be  the  first  object  of  the  investigator  to  learn  the  cause  of 
the  clouding.  This  is  accomplished  to  best  advantage  by  means  of  the 
microscope  after  sedimentation. 

To  propose  a  sequence,  then,  of  steps  of  urinary  examination,  it  is 
well  to  begin  with  the  double-glass  urine  specimens  that  have  been 
passed  voluntarily  by  the  patient  and  described  on  page  115.  In  inflam- 
matory conditions  the  second  portion  is  usually  the  clearer  of  the  two 
and  the  one  less  influenced  by  disturbances  in  the  anterior  urethra.  In 
passing  outward,  the  first  part  of  the  urine  carries  not  only  the  materials 
it  has  collected  in  the  bladder  and  upper  urinary  tract,  but  has  added  to 
it  products  from  the  urethra;  hence  its  greater  cloudiness.  Exceptions 
to  this  occur  when,  in  the  final  contractions  of  the  vesical  and  post- 
urethral  muscles,  blood  is  squeezed  from  an  acutely  inflamed  vesical 
neck;  or  incidental  to  the  same  act,  there  is  the  passage  of  spermatozoa 
from  the  seminal  vesicles  into  the  second  part  of  the  urine.  Then  the 
second  part  is  bloodier  or  cloudier,  as  the  case  mav  be,  than  the 
first. 

If  the  clouding  be  due  to  precipitated  phosphates ,  it  may  be  cleared 
by  the  addition  of  a  few  drops  of  acetic  acid;  if  due  to  precipitated 
urates,  warming  the  specimen  over  a  Bunsen  burner  will  cause  them 
to  redissolve.  But  if  these  simple  measures  do  not  at  once  succeed  in 
clearing  the  urine,  resort  must  be  had  to  the  more  definite  plan  of 
seeing  what  is  earning  the  clouding;  and  this  should  be  done  while  the 
specimen  is  fresh  and  unchanged  by  decomposition  or  bacterial  in- 
vasion. It  is  to  be  accomplished  by  microscopic  demonstration,  to 
which  no  chemical  test  or  other  method  is  comparable  in  accuracy  or 
completeness.  The  specimen  of  urine  is  sedimented  by  centrifuge;  the 
sediment  is  placed  unstained  ("fresh  specimen")  under  the  micro- 
scope, enabling  the  investigator  to  see  whether  motile  bacteria,  pus 
cells,  crystals,  blood  cells  or  what  not  produce  the  clouding.  Stain- 
ing of  the  same  sediment  brings  bacteria,  when  sparse,  into  more 
prominent  view,  and  permits  their  differentiation;  so  that  it  should 
be  the  next  step  of  the  investigation.  Naturally  the  staining  must 
accord  with  the  requirements  of  bacteriology  and  must  be  varied  accord- 
ing to  the  kind  of  organisms  suspected  to  be  present;  but  methylene 
blue  is  a  convenient  and  serviceable  stain  to  begin  with.  If,  in  a  sus- 


EXAMINATION  OF  THE   URINE  133 

pected  gonorrheal  case,  this  dye  demonstrates  diplococci  that  appear  to 
be  gonococci,  they  must  invariably  be  proved  to  be  such  by  means  of 
the  Gram  stain.  If  the  fuchsin  stain  appears  to  demonstrate  tubercle 
bacilli  they  must  be  proved  to  be  such  by  measures  that  leave  no  room 
for  doubt.  These  include  methods  of  acquiring  the  urine  specimen  that 
at  the  same  time  exclude  the  possibility  of  contamination  with  smegma 
bacilli,  and  may  include  inoculation  tests,  as  welL  The  question  of 
differentiating  between  tubercle  and  smegma  bacilli  by  processes  of 
staining  alone  has  been  discussed  elsewhere  (page  118)  with  the  conclu- 
sion that  no  such  possibility  should  be  entertained.  In  both  sexes  the 
urine  for  tubercle  bacilli  demonstration  should  be  obtained  by  cathe- 
terization  and  after  careful  cleansing  of  the  external  genitals.  With 
but  few  exceptions  it  may  be  said  that  the  finding  of  tubercle  bacilli  in  the 
urine  means  tuberculosis  of  one  or  both  kidneys.  That  truth,  the  deter- 
mination of  which  has  been  writhin-the  past  decade,  has  been  of  immeas- 
urable service  to  sufferers  from  urinary  tuberculosis — leading  the 
surgeon  to  disregard,  as  of  secondary  import,  the  tuberculous  implica- 
tion of  the  bladder  and  go  straight  to  the  source  of  trouble,  one  or  the 
other  kidney;  remove  it  and  reclaim  the  patient  to  health  and  the 
enjoyment  of  living. 

It  is  true  that  tubercle  bacilli  have  been  found  in  the  urine  of  patients 
who  had  no  renal  involvement,  but  were  tuberculous  elsewhere,  the 
bacilli  apparently  having  been  filtered  through  the  sound  kidneys  after 
being  conveyed  by  the  blood  from  the  original  focus.  But  the  dis- 
covery of  tubercle  bacilli  under  such  circumstances  is  so  rare  that  it 
should  be  viewed  more  as  a  pathological  curiosity  than  a  reality  to 
be  reckoned  with  in  the  clinic.  Practically,  then,  tubercle  bacilli  in 
the  urine  means  renal  tuberculosis.  The  next  question  is,  which  kid- 
ney ?  As  mentioned  elsewhere  (page  1 22) ,  ureteric  meatoscopy  through 
the  cystoscope,  though  relied  on  by  many,  should  be  supplanted  by  the 
surer  method  of  ureteral  catheterization,  by  which  means  is  learned 
not  only  which  kidney  is  to  blame  for  the  tuberculous  infection,  but 
also  the  condition  of  health  and  functional  activity  of  the  other  organ. 
The  answer  to  both  of  these  questions  is  absolutely  demanded  in  a 
complete  diagnosis. 

The  Absence  of  Tubercle  Bacilli. — The  inability  to  find  tubercle  bacilli 
in  a  suspected  urine  should  not  at  once  lead  to  false  hopes  of  their 
absence  and  to  what  may  later  prove  an  erroneous  diagnosis  of  non- 
tuberculous  infection.  While  latter-day  methods  have  increased  the 
ability  to  find  the  bacilli  when  present,  it  must  be  remembered  that 
even  with  active  and  severe  renal  tuberculosis  there  are  periods  in 
which  the  bacilli  do  not  appear  in  the  urine.  They  seem  to  be  pent  up 
for  the  time  being  in  the  suppurating  pockets,  to  escape  periodically 
in  the  so-called  showers  of  the  organisms,  easily  demonstrable  then  in 
countless  numbers.  The  necessary  deduction  is  that  in  a  suspected 
case  a  failure  to  find  tubercle  bacilli  should  count  for  nothing  and  should 
be  followed  by  many  repetitions,  if  necessary,  of  the  endeavor. 


134     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

Guinea-pig  Inoculation. — A  measure  that  often  proves  successful  in 
the  face  of  failure  by  direct  microscopic  investigation  is  that  of  inocu- 
lating a  guinea-pig  (or  two)  with  the  sediment  of  suspected  tuberculous 
urine.  Too  few  to  be  detected  by  the  microscope,  the  bacilli  are 
numerous  enough  to  respond  positively  to  this  more  refined  method  and 
develop  tuberculosis  in  the  animal,  showing  within  two  to  four  weeks. 
But  this  also  is  not  absolutely  reliable  as  to  negative  evidence,  since 
it  is  established  that  failure  to  inoculate  has  happened  with  urine  that 
later  was  proved  to  be  tuberculous  by  postmortem  demonstration. 
A  failure  of  this  sort  may  be  due  to  the  fact  that  the  attempted  inocula- 
tion is  made  during  a  quiescent  period,  between  showers  of  bacillary 
excretion,  or  to  some  other  cause.  At  any  rate,  because  of  the  unre- 
liability of  the  various  phases  of  negative  evidence,  one  is  reduced 
occasionally  to  make  a  diagnosis  instinctively,  so  to  speak:  Feeling, 
from  the  several  aspects  of  the  case,  that  it  is  tuberculous  at  bottom, 
even  though  the  ultimate  proof,  demonstration  of  the  presence  of  the 
tubercle  bacillus,  be  lacking. 

Tuberculin  Tests.— Tuberculin  tests  may  be  used  in  cases  of  suspected 
urinary  or  genital  tuberculosis,  and  occupy  the  same  position  as  when 
the  focus  of  infection  is  located  elsewhere  in  the  body.  Its  positive 
reactions  are  similar,  consisting  of  the  well-recognized  chill  or  chilliness, 
temperature,  aching  sensations;  and  in  urinary  infection,  local  reaction 
of  various  sorts:  Increased  pain  during  urination,  increased  frequency, 
occasionally  hematuria  or  increase  in  a  hematuria  already  present. 

Radiography  can  be  of  assistance  only  in  the  late  stages  of  a  renal 
tuberculosis  when  it  demonstrates  the  shadows  of  caseous  masses  in  a 
badly  damaged  kidney.  AYhen  this  condition  is  reached,  the  diagnosis 
has  doubtless  already  been  made  by  other  methods. 

Examination  of  Urine  Drawn  by  Ureteral  Catheters. — It  is  not 
always  practicable  or  desirable  to  draw  a  considerable  quantity  of 
urine  for  examination  after  ureteral  catheterization.  Both  the  time  of 
the  surgeon  and  the  safety  of  the  patient  militate  against  this.  Fortu- 
nately, it  is  not  necessary.  Two  or  three  drams  of  urine  are  usually 
sufficient  for  practical  purposes.  The  separated  urines  should  be  put 
through  the  same  processes  of  examination  as  have  been  applied  to 
the  other  specimens.  Albumin  due  to  the  presence  of  the  catheter 
in  the  ureter  will  nearly  always  be  found,  and  is  therefore  a  negligible 
element.  Sometimes  casts  appear  for  the  same  reason.  Blood  cells 
often  are  present  from  the  same  cause.  But  as  these  may  all  have  been 
absent  in  the  specimens  previously  examined,  they  are  recognized  as 
having  no  significance.  If  there  are  sufficient  blood  cells  present  to 
interfere  with  steps  of  the  examination,  they  may  be  at  once  dissolved 
and  eliminated  by  adding  a  few  drops  of  acetic  acid  to  the  specimen,  or, 
better,  a  drop  of  the  acid  to  the  sediment  on  a  slide.  This  also  clears 
up  the  pus  corpuscles  and  leaves  their  multinuclei  plainly  discernible 
as  compared  with  leukocytes,  white  blood  cells,  etc.  Round  epithelia 
are  usually  present  in  abundance  in  the  specimens  acquired  by  ureteral 
catheterization,  and  do  not  always  indicate  pathological  conditions, 


EXAMINATION  OF  THE   VRINE  135 

especially  if  unaccompanied  by  pus,  bacteria  or  other  evidence  of  dis- 
ease. Specific  gravity  of  small  quantities  of  urine  is  obtained  by  using 
gravity  beads  in  small  test-tubes ;  but  this,  also,  is  of  lesser  import, 
influenced  as  it  is  by  many  accompanying  conditions,  excitation  or 
inhibition  of  renal  excretion  from  instrumentation. 

Aside  from  the  determination  of  the  relative  functional  activity  of 
the  two  kidneys  (discussed  elsewhere),  the  chief  objects  to  be  attained 
in  examining  ureteral  catheterized  specimens  are:  Learning  whether 
pus  or  bacteria  (including  tubercle  bacilli)  are  present,  and  making  the 
differential  recognition  of  the  organisms  found;  learning  the  exact 
source  of  bleeding  which  is  present  before  the  catheterization;  compar- 
ing the  relative  activity  of  the  two  kidneys  writh  regard  to  quantity  of 
urine  secreted  in  a  given  time.  (For  insuring  against  error  in  this, 
precautions  must  be  taken  with  reference  to  leakage  on  one  side  or  the 
other  alongside  the  catheter  into  the  bladder,  instead  of  draining 
through  the  catheter);  and  relative  functional  activity. 

Complement  Fixation  Test. — In  inflammatory  conditions  of  the 
urinary  tract,  when  intracellular  groups  of  diplococci  are  found  by 
methylene  blue  or  other  of  the  anilin  dyes  and  they  are  decolorized  in 
the  Gram  stain,  the  diagnosis  of  gonococcus  infection  is  fixed  irrefutably. 
But  if  in  the  face  of  symptoms  and  history  simulating  those  of  gonor- 
rhea, or  if  there  is  a  question  of  recovery  from  gonorrhea  and  none  of  the 
organisms  can  be  found,  the  question  as  to  whether  the  gonococcal 
element  prevails  may  be  a  momentous  one,  yet  difficult  of  solution. 
The  tests  of  irritation  (beer,  nitrate  injection,  use  of  urethral  sounds) 
may  all  fail  and  leave  the  investigator  in  the  dark.  Cultural  methods 
are  not  always  satisfactory  or  available.  To  meet  this  dilemma  the 
complement-fixation  blood  test  was  devised  by  Miiller  and  Oppenheim 
in  1906,  the  efficacy  of  which  was  confirmed  by  Schwarz  and  McNeil8 
whose  contribution  on  the  subject  was  highly  appreciated  by  the 
profession.  Others  investigated  the  efficiency  and  reliability  of  this 
test  and  reports  of  Swinburne,  Schmidt,  Gardner  and  Clowes,  Gradwohl 
and  others  gave  strong  support  to  the  favorable  estimate  early  placed 
on  it. 

The  test  is  somewrhat  analogous  to  the  Wassermann  test.  It  is  based 
on  the  fact  that  microorganisms,  when  mixed  with  their  homologous 
antisera,  are  capable  of  rendering  complement  inactive  or  fixed,  as 
shown  by  the  absence  of  hemolysis  W7hen  sensitized  erythrocytes  are 
added  to  the  mixture.  The  antibody  is  produced  in  the  patient  by  the 
gonococci,  and  the  antigen  is  a  preparation  of  the  gonococci.  The 
fixation  of  complement  is  a  result  of  the  specific  interaction  between 
the  two.  For  details  of  preparation  and  use,  see  the  papers  by  the 
authors  alluded  to  (Trans.  Am.  Urolog.  Assn.,  1911-1912).  The  test  is 
now  available  in  practically  all  modern  laboratories,  and  should  be 
used  whenever  the  other  modes  of  diagnosticating  suspected  gonococcal 
infection  prove  unsatisfactory  or  uncertain, 

Wassermann  Tests :  Blood  and  Spinal  Fluid. — That  the  Wassermann 
blood  and  spinal  fluid  tests  have  great  practical  value  in  assisting  in  the 


136     METHODS  OF  DIAdXOMX  /A"  LKSIOXS  OF  I'KIXARY  TRACT 

solution  of  obscure  cases  of  urinary  obstruction  and  other  chronic 
genitourinary  disturbances,  is  becoming  widely  recognized.  These 
tests  should  be  applied  without  hesitation  in  all  cases,  young  or  old, 
whose  etiology  is  not  traced  or  understood.  The  writer  has  found 
syphilis  to  be  the  basic  and  controlling  factor  in  a  number  of  cases  of 
prostatic  obstruction,  urinary  retention  and  vesical  atony — cases  in 
which  there  had  never  been  the  slightest  suspicion  of  such  infection, 
although  it  had  evidently  been  present  for  years.  Even  hereditary 
syphilis  has  been  observed  in  the  same  light,  causing  chronic  and  severe 
urinary  obstruction  from  infancy  to  adolescence,  the  patient  meantime 
being  put  through  a  number  of  operative  measures  and  treatments  that 
served  only  to  aggravate  his  suffering^.  This  topic  is  discussed  at 
greater  length  in  a  paper  by  the  writer,  "Studies  in  Obscure  Forms  of 
Prostatic  Obstruction  and  Vesical  Atony."3 

The  chronic  retention  of  urine  from  locomotor  ataxia  is  but  a  similar 
manifestation  of  syphilis  and  its  late  effects  on  the  spinal  cord.  The 
modus  operandi  of  the  production  of  retention  in  these  and  similar 
cases  has  been  expressed  by  the  writer1  as  follows:  The  normal  filling 
and  emptying  of  the  bladder  is  accomplished  by  a  well-balanced 
relationship  between  the  detrusor  and  sphincteric  muscular  systems  of 
the  bladder.  If  there  is  incoordination  or  loss  of  balance  between 
these  two  systems,  there  is  derangement  of  the  function  of  urination. 
If  the  sphincteric  function  be  weakened  or  abolished,  there  is  leakage 
or  incontinence;  if  the  sphincteric  energy  be  excessive,  as  compared 
with  detrusive  power,  there  is  retention.  Sphincteric  energy  is  rela- 
tively stronger  when  the  detrusors  are  weakened  from  any  cause.  In 
atony,  for  instance,  while  the  sphincters  may  not  actually  have  gained 
any  strength  through  the  establishment  of  that  condition,  they  offer 
sufficient  resistance  to  the  now  weakened  detrusors  to  interfere  with  the 
discharge  of  their  function;  a  certain  amount  of  urine  is  left  over  after 
each  urination.  The  insertion  of  a  catheter  removes  the  effect  of  the 
sphincters,  opens  the  outlet  and  restores  the  original  balance  between 
the  two  opposing  systems.  The  detrusors  demonstrate  their  remaining, 
though  weakened,  power  and  readily  empty  the  bladder. 

It  is  incumbent  on  the  diagnostician  to  differentiate  between  these 
conditions,  and  also  to  trace  the  cause  of  the  disturbances  described. 

CARDIOVASCULAR  EXAMINATION. 

As  suggested  under  a  previous  heading,  an  examination  of  the  allied 
organs,  the  kidneys  and  cardiovascular  system,  is  of  the  utmost 
importance  in  its  bearing  on  the  outcome  of  a  contemplated  major 
surgical  operation;  and  may  have  much  to  do  with  success  or  failure 
in  non-operative  plans  of  treatment  in  certain  affections,  especially 
of  the  kidneys.  Cardiac  functionating  is  intimately  associated  with 
renal  activity  and  competence.  Nothing  shows  this  more  plainly  than 
the  success  that  frequently  follows  the  prescribing  of  efficient  heart 
tonics  in  the  presence  of  lagging  kidneys.  The  heart  grows  energetic, 


DIAGNOSIS  OF  OBSTRUCTIONS  IN  THE  URINARY  TRACT     137 

circulation  becomes  better,  the  kidneys  respond  with  more  and  better 
urine  and  improvement  becomes  manifest  in  every  respect. 

In  determining  the  condition  and  efficiency  of  the  heart  and  vascular 
system,  besides  the  methods  of  examination  regularly  employed,  the 
blood-pressure  should  be  accurately  taken.  Some  operators  consider 
this  to  be  as  important  as  the  urinary  findings  as  a  gauge  on  the  physical 
condition  and  powers  of  resistance  to  the  shock  of  operation.  A  press- 
ure unduly  high  or  low  may  well  be  considered  as  directly  suggestive  of 
the  propriety  of  postponing  a  contemplated  operation  until  such  time 
as  various  corrective  measures  may  bring  about  a  more  favorable 
condition. 


DIAGNOSIS    OF    OBSTRUCTIONS   IN    THE    URINARY    TRACT. 

Obstructions  in  the  urinary  tract  must  be  diagnosed  with  reference 
to  (a)  location;  (b)  form  and  nature;  and  (c)  severity.  They  occur  at 
any  point  between  the  preputial  orifice,  and  the  urinary  tubules  of  the 
kidneys.  There  are  definite  and  well-conceived  methods  of  attaining 
the  above-mentioned  objects  in  diagnosis. 

Urethral  Obstructions. — Obstructions  located  at  the  preputial  or 
external  meatal  orifice  are  patent  to  observation  and  require  no  com- 
ment other  than  a  gentle  expression  of  regret  that  physicians  do  not 
always  make  even  the  cursory  inspection  of  these  parts  that  wrould 
locate  the  source  of  trouble,  which  is  often  on  that  account  severe  and 
unnecessarily  prolonged.  In  children  kidneys  have  been  destroyed 
through  backward  pressure  from  so  simple  a  cause  as  a  narrow  meatus 
or  a  tight  prepuce.  The  tissues  surrounding  a  narrow  meatus  gradually 
merge  into  a  dense  fibrous  ring,  producing,  through  backward  pressure, 
insidious  but  disastrous  effects  on  the  organs  above.  Invalidism  and  a 
shortened  life  may  be  the  consequence. 

Obstruction  of  the  urethra  at  any  point  offers  little  difficulty  of 
detection.  Suspicious  symptoms  or  history  should  lead  to  direct 
examination  of  the  urethra  by  bulb  sounds,  which,  the  larger  sizes 
being  used  first,  will  demonstrate  the  "hitch"  of  a  stricture,  its  size 
and  extent;  or  the  obstructive  presence,  and  possibly  the  grating  feel 
of  a  foreign  body. 

The  bulb  sounds  are  useful  for  the  anterior  urethra,  but  the  large 
size  conical  steel  sounds  are  preferable  for  the  posterior  part  of  the 
canal.  A  tight  stricture  at  this  point  will  obstruct  a  steel  sound  with- 
out the  objectionable  grasping  of  the  bulbs.  E.  G.  Mark1  expresses  his 
belief  that  one  of  the  most  satisfactory  methods  of  diagnosticating 
urethral  stricture  is  that  by  means  of  the  aero-urethroscope.  This  gives 
a  plain  and  clean-cut  view  of  the  constricted  area,  as  well  as  of  the 
adjacent  healthier  portion.  Such  a  view  also  leads  to  more  definite 
indications  as  to  the  treatment,  it  is  claimed. 

Obstruction  at  the  Vesical  Neck. — The  demonstration  of  obstruction 
located  at  the  vesical  neck  rather  than  at  some  point  in  the  urethra  is 


138     METHODS  OF  DIAG.\OXIX  IN  LKXIOXX  OF  I'RIXARY  TRACT 

made  in  the  following  way:  In  a  given  case  the  symptoms  of  which 
point  to  obstruction  somewhere,  the  patient  is  instructed  to  pass  his 
urine  (all  that  he  can)  by  voluntary  effort;  after  which  a  soft-rubber 
catheter  is  passed  if  possible  into  the  bladder.  This  immediately 
shows  whether  or  not  residual  urine  has  been  leftover  after  the  volun- 
tary urination.  Five,  ten  or  twenty  ounces  residual  urine  thus  obtained 
is  clear  evidence  of  marked  obstruction;  and  also  that  the  obstruction  is 
located  at  the  neck.  So  marked  an  obstruction  as  this  (5  to  20  ounces 
residuum)  if  in  the  form  of  a  urethra!  stricture,  would  stop  the  passage  of 
a  soft  catheter  before  it  arrives  at  the  neck;  whereas,  prostatic  obstruc- 
tion, in  the  first  place,  does  not  make  itself  evident  to  a  catheter  until 
the  depth  of  the  vesical  neck  is  reached ;  and,  in  the  second,  prostatic 
obstruction  is  usually  surmounted  by  a  soft-rubber  catheter  of  good 
size  and  quality.  In  brief,  therefore,  the  drawing  off,  by  means  of 
a  good  sized  rubber  catheter  (Xo.  18),  of  a  pronounced  amount  of  residual 
urine  after  voluntary  urination  indicates  obstruction  at  the  neck.  If, 
on  the  other  hand,  the  progress  of  the  soft  catheter  is  suddenly  stopped 
before  reaching  the  vesical  neck,  we  know  the  obstruction  is  urethral; 
and  in  all  probability  is  either  a  stricture  or  a  manifestation  of  the 
obstructing  influence  of  the  cut-off  muscle  (compressor  urethrse).  The 
differentiation  between  these  is  made  by  means  of  the  bulb  and  conical 
steel  sounds.  TJie  muscle  offers  obstruction  to  the  bulbs  but  not  to 
the  steel  sounds.  Pronounced  stricture  offers  obstruction  to  both.  By 
these  tests,  then,  is  learned  (n)  whether  there  is  obstruction;  (6)  the 
severity  of  the  obstruction;  and  (c)  its  location. 

If  the  obstruction  is  thus  found  to  be  located  at  the  neck,  the  problem 
resolves  itself  into  the  determination  of  the  remainder  of  the  diagnostic 
points  previously  described,  namely,  the  form,  character  and  other 
physical  characteristics  of  the  obstructing  factor  at  the  neck;  and  the 
determination  of  the  condition,  functional  activity,  etc.,  of  the  allied 
organs,  the  heart  and  kidneys. 

Prom  the  view-point  of  obstruction,  the  vesical  neck  is  undoubtedly 
the  most  interesting  part  of  the  urinary  tract.  While  many  forms 
of  obstruction  here  met  with  are  readily  differentiated  under  the  plans 
of  examination  already  described,  there  are  many  others  in  which  the 
cause  is  not  easily  determined.  It  may  be  obscure  and  may  never  be 
identified.  The  patient  then  is  either  classed  as  incurable  or  joins  the 
host  of  "journeymen  patients"  who  go  unrelieved  through  the  hands  of 
physicians,  thence  to  quacks,  to  osteopaths,  "scientists"  and  down  the 
line  of  fakery. 

With  its  importance  and  far-reaching  influence  in  mind  the  writer, 
in  discussing  this  subject  at  length  elsewhere,3  expressed  himself  as 
follows:  "The  causation  of  urinary  obstruction  should  always  be 
found  in  one  of  two  factors,  namely,  (a)  physical  obstruction  of 
some  kind  or  (6)  disturbance  of  the  nervous  mechanism  controlling 
urination  (tabes,  spinal  or  cerebral  lesions,  etc.).  There  is  no  such 
thing  as  'unaccountable'  atony  or  urinary  retention;  such  a  term 
represents  incomplete  diagnosis.  The  most  frequent  and  important 


DIAGNOSIS  OF  OBSTRUCTIONS  IN  THE  URINARY  TRACT     139 

of  the  obscure,  unrecognized  causes  of  obstruction  are:  (a)  Ill-defined 
contracture  at  the  vesical  neck  demonstrable  sometimes  only  by 
palpation  through  the  opened  bladder  or  urethra;  (6)  unrecognized 
syphilis,  acquired  or  hereditary,  affecting  the  spinal  centres.  Such  con- 
ditions are  by  no  means  confined  to  adult  life,  and  should  be  looked  for 
at  any  age,  from  infancy  up;  diagnosed  and  treated  in  accordance  with 
the  refined  diagnosis  always  demanded  in  cases  of  urinary  obstruction. 
A  final,  but  too  late  recognition  is  but  poor  solace  for  a  lifetime  of 
suffering  due  to  delinquencies  in  diagnosis." 

Causes  of  Obstruction  at  the  Vesical  Neck. — The  causes  of  obstruction 
at  this  point  are  multifarious.  They  include  disturbances  both  local 
and  general  or  internal ,  primary  or  secondary ,  congenital  or  acquired, 
and  are  capable  of  being  subdivided  as  to  etiology  as  follows: 

Local  causes: 

1.  Prostatic  overgrowths  (adenoma); 

2.  Contracture; 

3.  Cyst  formation; 

4.  Abscess; 

5.  Congestion  or  Inflammation; 

6.  Neoplasm,  benign  or  malignant; 

7.  Calculus; 

8.  Foreign  body; 

9.  Valve  formation  in  prostatic  urethra; 

10.  Cyst  or  tumor  of  verumontanum ; 

11.  Inflammation  of  seminal  vesicles; 

12.  Infection  (colon  bacilluria  of  little  girls); 

13.  Hemorrhage  (clot  formation). 
Internal  or  systemic  causes: 

1.  Cerebral  (meningitis,  hemorrhage); 

2.  Spinal  (paresis,  tabes,  spinal  syphilis) ; 

3.  Habit  (deferred  urination  of  teachers  and  others) ; 

4.  Fatigue  (Peyer); 

5.  Neurotic  (hysteria,  nymphomania) ; 

6.  Psychic  (fixed  idea) ; 

7.  Reflex  (secondary  to  irritations  originating  elsewhere;  post- 

operative; shock). 

8.  Toxic  (alcoholism,  diabetic  coma;  acidosis,  effect  of  drugs). 
The  number  and  variety  of  causes  of  obstruction  at  the  vesical  neck 

afford  no  excuse  for  not  making  the  required  recognition  and  differ- 
entiation. Indeed,  these  must  be  made  in  order  to  choose  an  appro- 
priate treatment.  Aside  from  an  intelligent  study  of  symptoms  and 
signs,  the  cystoscope  and  posterior  urethroscope  afford  the  greatest 
assistance  in  arriving  at  diagnostic  conclusions.  These  instruments  are 
not  interchangeable.  A  lens  appropriate  for  the  close-vision  work  of 
urethroscopy  is  inefficient  and  inappropriate  for  cystoscopy;  and  the 
relatively  long  distance  focus  of  the  cystoscope  lens  is  inappropriate 
for  intra-urethral  vision.  For  discussion  of  diagnostic  instruments  see 
page  118. 


140    METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

Obstruction  in  the  Bladder. — Obstruction  and  urinary  retention 
sometimes  occur  from  causes  located  within  the  bladder  itself;  such 
as  foreign  bodies,  stones,  tumors,  etc.;  or  diverticula,  whose  lack  of 
muscular  equipment  prevents  them  from  contracting  and  emptying 
their  contents  into  the  bladder  cavity.  Cystoscopy  is  the  chief  agency 
for  determining  the  diagnosis  in  such  cases,  although  much  may  be 
done  with  radiography,  using  collargol  or  silver  iodide  solutions  for 
distending  the  bladder.  Deviations  from  normal  size  and  form  are 
thus  to  be  recognized. 

Obstruction  in  the  Ureter. — Ureteral  stricture  is  not  as  rare  a 
condition  as  its  lack  of  recognition  in  general  would  indicate.  Occur- 
ring independently,  or  in  connection  with  ureteral  stone,  the  symptoms 
of  both  are  often  intertwined.  Mucopus  plugs  passing  down  a  ureter 
and  becoming  impacted  in  a  strictured  area  act  like  stones  and  are 
followed  by  similar  consequences  of  distention,  pain,  colic,  chills  or 
fever  and  infection.  The  effects  resemble  those  of  stone  colic  so  closely 
that  the  differentiation  is  often  made  only  with  difficulty  and  with  the 
aid  of  ureteral  catheterization  and  radiography.  A  catheter  is  usually 
obstructed  or  stopped  in  its  passage  up  the  ureter  on  coming  in  contact 
with  a  stricture ;  and  is  frequently,  though  not  always,  obstructed  by 
the  presence  of  ureteral  stone.  But  the  progress  of  a  catheter  may  be 
stopped  from  too  great  angulation  of  the  ureter  channel  or  from  spasm 
of  the  ureteric  muscles,  to  be  overcome  in  both  instances  by  appropriate 
measures:  Changing  the  course  or  direction  of  the  catheter,  in  the 
first,  and  making  steady  pressure  with  the  catheter  and  awaiting 
relaxation  of  the  spasm,  in  the  second  will  usually  overcome  the 
abstacle.  A  ureteral  band,  pressure  from  an  anomalous  vessel  or 
adhesions,  are  other  causes  of  ureteral  obstruction  whose  differentia- 
tion is  assisted  by  catheterization  and  pyelography.  The  efficiency 
of  these  measures  in  diagnosis  has  gradually  lessened  the  utility  and 
necessity  of  the  old  stock  reliance,  exploratory  operation,  in  surgery  of 
the  upper  urinary  tract.  Time  was  when  surgeons  opened  the  bladder 
to  see  whether  or  not  the  prostate  was  enlarged,  but  such  a  pro- 
cedure would  hardly  be  countenanced  now  except  in  the  presence  of 
very  complicated  conditions. 

Obstruction  in  the  Renal  Pelvis. — This  is  produced  by  stone  forma- 
tion, constriction  from  stricture,  adhesions,  kink,  anomalous  vessel,  or 
malignant  growth,  and  sometimes  from  plugging  of  the  outlet  by 
the  products  of  inflammation,  crystalline  sedimentation,  or  hemor- 
rhage. 

The  typical  characteristic  distress-signal  of  Nature  indicating  any  of 
these  conditions  is  pain,  intense,  repeated,  horrid;  described  by  some 
as  possessing  all  the  tortures  conceivable.  Where  the  stone  forms  in 
the  kidney  tissue,  especially  in  the  cortical  portion,  the  pain  is  less 
insistent;  indeed,  it  may  be  insignificant  or  even  absent  throughout  the 
progress  of  destruction  of  the  organ.  But  this  well-established  fact 
should  not  justify  a  failure  to  trace  and  find  the  offending  stone,  no 
matter  how  insidious  its  development  nor  retired  its  situation.  Investi- 


SYMPTOMATOLOGY  IN  GEN  I  TO-URINARY  DISEASES       141 

gation  along  the  lines  of  comprehensive  physical  examination  should 
divulge  the  secrets  of  all  eases  and  evoke  relief  before  the  period  when 
decreptitude  and  participation  of  the  opposite  kidney  preclude  chances 
of  reclamation. 

Pathological  evidences  of  obstruction  in  the  pelvis  consist  in  hydro- 
nephrosis,  pyonephrosis,  thinned,  sacculated  and  destroyed  kidneys,  the 
latter  being  sometimes  nothing  but  a  thin-walled  sack,  incapable  of 
excreting  real  urine,  but  perhaps  carrying  on  a  process  of  filtration 
of  thin,  worthless  fluid  incapable  of  performing  the  renal  scavenger 
service  required  for  life  and  health. 

SYMPTOMATOLOGY  IN  GENITO-URINARY  DISEASES. 

The  writer  has  always  considered  the  extended  discussion  of  urologic 
symptomatology  as  detrimental  to  the  attainment  of  correct  and  useful 
diagnosis,  rather  than  the  contrary.  Such  symptomatology  is  inexact 
and  often  illusory,  as  has  been  previously  shown,  and  cannot  be  given 
much  credence  even  by  the  initiated.  How  much  less  reliance,  then, 
can  be  placed  on  it  by  those  who  are  doing  general  practice  and  do  not 
possess  experience  in  this  special  work  that  would  keep  them  out  of 
the  pitfalls  ever  present.  The  symptoms  under  such  circumstances 
assume  more  the  character  of  will-o'-the-wisps,  leading  practitioner  and 
patient  on  and  on  from  one  erroneous  assumption  to  another,  the  while 
postponing  the  day  of  definite  reckoning,  exact  diagnosis  and  correct 
treatment  until  the  arrival  of  the  unhappy  time  when  everyone  realizes 
that  it  is  too  late;  that  opportunity  has  fled  from  the  poor  sufferer, 
leaving  in  its  wake  only  the  miserable  duty  of  palliation  until  death 
relieves.  The  betrayal  has  been  made  through  the  guile  of  plausible 
but  illusory  symptoms. 

Used  in  their  proper  light,  however,  urinary  symptoms  are  valuable 
and  serviceable  for  paving  the  way  to  recovery.  They  should  be 
received  as  pointing  the  way,  not  to  diagnosis,  but  to  appropriate 
methods  and  steps  of  physical  examination,  on  which  must  rest  the 
development  of  the  diagnosis.  This  is  "a  real  situation  in'  urology 
and  is  met  with  every  day  of  the  year,  the  country  over.  Its  considera- 
tion, therefore,  and  its  reiteration  are  worth  while.  Whatever  is 
said  of  symptomatology,  in  this  or  any  other  review,  should  be  said 
with  those  thoughts  ever  in  mind. 

Symptoms  of  Urethral  Affections  in  the  Male. — The  anatomico- 
physiological  division  of  the  male  urethra  into  anterior  and  posterior 
portions  markedly  influences  the  symptomatology  of  this  tract.  Be- 
tween the  placid  progress  of  an  anterior  urethritis  and  the  urgent  and 
impetuous  invasion  of  the  posterior  urethra  there  is  a  wide  difference. 
Frequency  and  urgency  of  urination  usually  mark  the  transition;  and 
inspection  of  the  urines  confirms  the  suspicion:  The  two  (or  three) 
glasses  are  found  to  be  cloudy,  instead  of  the  clouding  being  confined 
to  the  first  glass,  as  has  been  the  case  up  to  that  time. 

With  subsidence  in  the  intensity  of  the  posterior  inflammation  there 


142     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

is  usually  decrease  in  the  unwonted  frequency  until  often,  even  with 
persistence  of  a  low-grade  inflammation  and  moderate  infection  there 
may  be  no  greater  frequency  than  normal.  Also,  under  the  same 
circumstances,  there  may  be  no  purulent  discharge  at  the  external 
meatus;  and  if  one  were  guided  by  symptoms  alone,  he  might  pro- 
nounce such  a  patient  well  and  permit  him  to  resume  intercourse  though 
he  were  as  infectious  as  during  the  more  active  stages. 

In  the  misconception  that  undue  frequency  of  urination  means 
cystitis,  the  irritative  symptoms  of  posterior  urethral  infection  are 
often  ascribed  to  the  bladder.  As  a  matter  of  fact,  the  sensation  of 
desire  to  urinate  arises  in  the  posterior  urethra,  and  excessive  frequency 
is  an  indication  of  irritation  of  the  posterior  urethral  membrane.  \Vere 
the  bladder  mucosa  the  seat  of  the  sensation,  desire  to  urinate  would  be 
aroused  practically  all  of  the  time,  as  the  bladder  nearly  always  contains 
some  urine — even  shortly  after  urination,  when  it  is  refilling. 

Vesical  Symptoms. — Pain  deep  in  the  pubic  region  and  a  disagreeable 
feeling  of  fulness  are  often  present  with  cystitis.  In  connection  with 
the  presence  of  a  stone  in  the  bladder  there  is  described  by  the  patient 
the  sudden  interruption  of  the  urinary  stream  and,  after  a  pause,  the 
resumption  of  the  flow.  These  are  the  most  characteristic  symptoms 
pointing  to  disturbances  within  the  bladder.  But  they  are  not  to  be 
relied  on  for  differentiation,  even  with  the  addition  of  blood  in  the 
urine,  as  the  same  conditions  and  interruptions  may  be  brought  about 
by  the  presence  of  a  pedunculated  tumor  in  the  bladder,  intermittently 
plugging  the  outlet  and  interrupting  the  stream  as  does  the  stone. 

Prostatic  and  Seminal  Vesicular  Symptoms. — A  symptom  almost  con- 
stantly attendant  on  prostatic  inflammation,  either  from  abscess  forma- 
tion or  in  connection  with  acute  retention  from  hypertrophy,  is  pain  in 
the  glans  penis.  Complaint  of  such  pain,  in  the  absence  of  apparent 
disturbance  of  the  glans,  should  arouse  suspicion  of  prostatic  disturbance 
and  lead  to  the  rectal  palpation  that  should  determine  the  question. 
Active  irritation  in  the  vesicles  often  produces  an  uncomfortable  "  bear- 
ing-down" feeling  in  the  perineum  with  a  sensation  of  fulness  there;  or, 
the  pain  may  be  transmitted  down  the  spermatic  cord  into  the  testicle 
of  the  side  affected.  Chills  or  elevation  of  temperature  in  connection 
with  any  of  these  conditions  depend  on  the  acuteness  and  intensity  of 
the  process,  and  may  or  may  not  be  present. 

A  sign  of  atonicity  of  the  ejaculatory  ducts  is  given  in  the  recurrent 
escape  with  urination  of  spermatozoa  from  the  seminal  vesicles.  Sig- 
nificant evidence  of  this  appears  in  the  two-glass  urine  test:  In  this 
case  the  second  glass  is  cloudier  than  the  first,  an  exception  to  the  rule 
as  already  mentioned.  The  clouding,  on  microscopic  examination, 
is  found  to  be  from  numbers  of  spermatozoa. 

Ureteral  Symptoms. — Ureteritis  sometimes  presents  symptoms,  some- 
times not.  If  present,  they  may  show  as  a  fixed  or  intermittent  pain 
in  the  line  of  the  ureter,  extending  downward  into  the  scrotum  and  testis 
of  the  corresponding  side;  to  which  may  be  added  an  irritation  reflected 
into  the  posterior  urethra  that  evokes  frequency  of  urination  or  even 


SYMPTOMATOLOGY  IN  GEN  I  TO-URINARY  DISEASES       143 

strangury.  Tenderness  in  the  line  of  the  ureter  is  also  characteristic  of 
ureteritis.  This  is  accentuated  when  one  comes  to  catheterize  that 
ureter  through  the  cystoscope;  and  further  confirmation  is  obtained  in 
the  contents  of  the  urine  drawn  from  that  side :  pus,  bacteria,  epithelia 
and  blood  cells. 

Ureteral  Stone. — By  blocking  the  ureter  and  damming  the  urine  back 
into  the  kidney,  and  also  by  arousing  spasmodic  contractions  of  the 
ureteral  muscles,  ureteral  stone  often  becomes  one  of  the  most  painful 
conditions  aft'ecting  the  human  body;  and  such  attacks  may  recur  at 
irregular  intervals  for  many  years,  subjecting  the  patient  to  the  mortal 
dread,  as  \vell  as  the  realization  of  their  horrors.  When  the  stone  is 
smooth  and  oval,  and  leaves  room  for  the  passage  of  urine  beside  it, 
there  may  be  no  more  than  an  occasional  dull  ache  in  the  vicinity  of  its 
location;  and  this,  notwithstanding  that  the  kidney  above  it  may  be 
undergoing  damage  and  gradual  destruction  through  infective  and 
insidious  back-pressure  influences.  Nausea  and  vomiting  often  occur 
in  connection  with  such  ureteral  crises. 

Renal  Pelvic  Symptoms. — Chronic  backache  that  has,  by  the  laity, 
been  ascribed  to  "kidney  disease"  is  more  closely  and  typically  con- 
nected with  pyelitis  than  with  nephritis,  of  the  chronic  form.  The 
amount  and  intensity  of  pain  caused  by  a  stone  in  the  pelvis  depends 
largely  on  whether  it  falls  into  the  ureteropelvic  outlet  and  blocks  the 
escape  of  urine.  But  even  aside  from  that  it  may  be  said  that  a  stone 
moving  about  in  a  pelvis  and  thereby  irritating  it  arouses  much  more 
pain  than  does  the  stone  that  grows  while  fixed  immovably  in  the 
cortex,  even  though  the  destructive  effect  may  be  as  great  with  the 
latter.  Many  cases  have  been  observed  in  wrhich  kidneys  had  been 
utterly  destroyed — found  so  at  postmortem  examination — without  any 
complaint  of  backache  having  been  made  during  life. 

Probably  the  most  typical  sign  of  severe  pyelitis  is  the  persistent 
loading  of  the  urine  with  pus,  continuing  perhaps  over  many  years. 
The  very  absence  of  other  symptoms  in  the  presence  of  excessive 
pyuria  is  in  itself  sufficient  to  cause  a  suspicion  of  pyelitis  and  call  for  the 
cystoscopy  and  ureteral  catheter ization  that  are  needed  to  solve  the 
question.  Of  course  the  determination  of  pyelitis  by  such  means  is 
only  one  step  in  the  procedure,  and  the  cause  of  the  pyelitis  is  also  to 
be  learned:  Whether  from  stone,  tumor  or  infection;  and  if  the  latter, 
what  kind  (colon  bacillary,  tuberculous,  gonococcal,  etc.).  It  is  sur- 
prising how  long  such  pelvic  suppuration  may  go  on  without  making 
marked  inroads  on  the  general  health  of  the  patient.  A  patient  of  the 
writer  showed  urine  that  by  bulk  was  almost  a  third  pus  on  settling, 
and  declared  that  the  same  thing  had  been  going  on  for  twenty  years; 
and  without  apparent  detriment  to  his  general  health. 

Movable  and  displaced  kidneys  produce  symptoms  of  pain  and 
systemic  reaction,  nausea  and  vomiting  harmonizing  with  the  occur- 
rence of  displacement  and  obstruction  to  circulation  and  urine  escape 
incidental  thereto.  Such  attacks  are  called  Dietl's  crises,  a  term  given 
in  recognition  of  their  graphic  description  and  explanation  in  1864,  by 
Diet). 


144     METHODS  OF  DIAGXUSIX  IX  LESIONS  OF  URIXARY  TRACT 

Genital  Symptoms. — Symptoms  of  pain  connected  with  diseases  of 
testis  or  scrotum  are  sufficiently  localized  to  disclose  their  identity, 
with  certain  exceptions.  The  writer  recalls  an  instance  in  which  a  bed- 
ridden patient  was  crying  out  with  plaints  of  pain  in  the  back  and  could 
give  no  clue  to  the  cause  until  an  extended  search  disclosed  the  existence 
of  acute  swelling  and  inflammation  of  one  testicle,  of  which  the  patient 
was  not  aware  until  it  was  shown  to  him.  It  showed  where  the  reflexes 
of  ttsticular  pain  might  be  looked  for:  Up  the  cord  and  into  the  back. 
Disturbances  of  the  cord  tend  to  reflect  pain  in  the  same  direction. 

Urologic  Symptomatology  in  Women.  —  Urethral  Symptoms.  —  In 
women  the  short  urethra  is  undivided  by  a  cut-off  muscle,  and  the 
symptomatology  presents  no  such  variations  according  to  location  of  in- 
volvement as  are  found  in  the  male.  The  female  urethra,  nevertheless, 
is  the  source  of  much  suffering  and  intensely  painful  symptomatology, 
which,  curiously  enough,  is  nearly  always  ascribed  to  the  bladder  by  the 
sufferers.  Designated  as  "cystitis,"  such  urethra!  irritations,  inflam- 
mations and  contractures  go  for  years,  often  with  no  better  treatment 
than  some  internal  medicine  and  perhaps  an  occasional  washing  of  the 
bladder — an  organ  that  is  merely  an  innocent  bystander  in  multitudes 
of  such  instances. 

The  symptoms  complained  of,  then,  are  undue  frequency  and  urgency 
of  urination,  often  painful  urination,  accompanied  with  straining  or 
incomplete  emptying  of  the  bladder;  and  all  with  or  without  clouding 
or  infection  of  the  urine.  Some  patients  show  crystal-clear  urine  yet 
complain  strenuously  from  adolescence  to  middle  life.  Some  relate  that 
the  same  conditions  have  prevailed  since  childhood.  Others  give  the 
birth  of  their  first  child  as  the  date  of  beginning;  while  still  others  note 
the  close  and  suspicious  relationship  between  marriage  and  the  begin- 
ning of  their  "bladder  trouble."  At  any  rate,  like  the  poor,  it  seems 
ever  present  with  them.  A  recent  patient  of  the  writer  was  certain 
that  she  had  had  the  same  symptomatology  for  thirty-eight  years;  yet 
she  became  well  within  a  month  after  appropriate  treatment,  based  on  a 
correct  diagnosis,  had  been  applied.  In  this  case  the  urethra  only  was 
involved,  in  the  form  of  a  narrow  stricture  at  the  meatus,  causing 
obstruction  and  urethritis  behind  it. 

In  these  conditions,  as  well  as  in  those  in  which  the  female  vesical 
neck  is  particularly  involved,  the  symptomatic  expression  is  chiefly 
frequency  of  urination  and  an  inability  to  retard  urination  when  once 
the  desire  is  felt.  It  occurs  in  the  young,  the  middle-aged  and  the 
old.  Yesical  symptoms,  pain  and  aching  feelings  often  originate  from 
disturbances  in  the  uterus  or  malpositions  of  that  organ,  causing  it  to 
impinge  on  or  distort  the  bladder.  Cystoscopically,  one  may  often  see 
the  dome-shaped  body  of  the  fundus  uteri  as  it  encroaches  on  the 
bladder  cavity. 

The  symptomatology  of  the  remaining  urinary  organs  of  women 
do  not  differ  materially  from  that  described  for  men,  and  requires  no 
further  special  mention. 

Hematuria,  pyuria,  bacteriuria  when  sufficiently  pronounced  are  evi- 


SYMPTOMATOLOGY  IN  GEN  I  TO-URINARY  DISEASES       145 

dent  to  the  naked  eye,  and  on  being  thus  observed  should  always  impel 
the  practitioner  to  make  or  have  made  the  definite  investigation  that 
should  disclose  their  source  and  causation.  Under  no  circumstances 
a  hurt  of  actual  danger  from  /o.v.v  of  blood  should  an  endeavor  be  made  by 
medicines,  etc.,  to  check  hematuria  until  opportunity  is  had  for  cysto- 
scopic  diagnosis  of  the  source  and  causation  of  the  bleeding.  It  is  of 
greatest  importance  to  have  the  cystoscopy  done  while  the  bleeding  in- 
going on.  When  it  stops,  the  urine  may  be  as  clear  as  crystal  and  give 
no  tangible  evidence  of  whence  came  the  alarming  hematuria  of  a  few 
days  previously.  To  bring  about  a  temporary  clearing  of  the  urine  of 
blood  is  no  real  accomplishment  and  postpones  the  making  of  a  definite 
diagnosis;  so  that  the  more  successful  the  practitioner  is  in  that 
endeavor,  the  more  he  is  liable  to  injure  the  prospects  of  his  patient. 

To  depend  on  the  color  of  the  blood  as  indicating  whether  it  has 
come  from  bladder,  ureters  or  kidneys,  is  fallacious  in  the  extreme  and 
should  not  be  entertained  for  a  moment.  The  crucial  test  is  the  use 
of  cystoscopy  and  ureteral  catheterization,  with  possibly  the  addition 
of  radiography. 

Phosphaturia,  oxaluria,  uric  acid  excess  and  other  like  conditions 
are  indicative  of  disturbances  of  metabolism.  Their  irritating  influ- 
ences sometimes  excite  an  irritation  of  the  urethra  that  may  become 
quite  an  active  urethritis,  not  easily  controlled  unless  the  causation  is 
recognized  and  is  eliminated  at  the  source.  The  writer  has  seen  cases 
in  the  males  that,  excepting  for  the  absence  of  gonococci  in  the  dis- 
charge, closely  resembled  gonorrheal  urethritis.  These  are  among  the 
so-called  "simple  urethritis"  cases.  The  diagnosis  is  arrived  at  by 
examination  of  the  urine  and  identifying  the  causal  element  therein. 

Physical  Examination  of  Women. — The  patient  should  be  cautioned 
against  taking  a  douche  or  urinating  shortly  before  undergoing  exami- 
nation— something  that  prospective  patients  are  prone  to  do.  Such 
action  only  washes  out  the  inflammatory  products  and  disguises  the 
real  situation.  If  the  woman  is  being  examined  because  of  a  suspicion  of 
gonococcal  infection,  inspection  of  the  external  genitals  should  be  the 
first  step,  a  little  pressure  with  the  finger  being  made  under  the  meatus 
to  express  any  urethra!  discharge  that  may  be  present.  If  none  is 
found,  the  meatus  may  be  cleaned  with  moist  cotton  and  the  patient 
requested  to  urinate  in  a  sterile  vessel,  both  for  macroscopic  and  micro- 
scopic examination.  Such  a  urine  specimen  will  contain  vaginal  epi- 
thelia  in  abundance;  and  if  urethritis  be  present,  evidence  of  it  will  be 
shown  in  the  pus  and  other  inflammatory  products,  possibly  with 
gonococci,  attained  by  sedimentation  and  staining.  If  it  is  desired  to 
examine  for  tubercle  bacilli,  the  specimen  for  this  purpose  should  be 
drawn  by  catheter  directly  from  the  bladder. 

Continuing  the  physical  examination,  a  vaginal  speculum  is  intro- 
duced and  the  cervix  is  inspected.  Some  of  its  secretion  may  be  mopped 
up  with  a  small  cotton  swab  and  transferred  to  glass  slides  for  staining. 
It  is  scarcely  worth  while  to  take  secretion  from  the  vaginal  wall,  as  the 
bacteria  are  naturally  so  numerous  in  the  vagina  that  no  particular 

M  U      I — 10 


146     METHODS  OF  DIAGNOSIS  IN  LESIONS  OF  URINARY  TRACT 

forms  can  be  identified  in  this  way.  The  cervical  canal  and  uterine 
cavity  may  be  sounded  by  the  uterine  probe,  for  information  as  to 
depth  and  conformation.  The  remainder  of  the  physical  examination 
is  to  be  made  by  bimanual  palpation,  with  the  patient  on  the  back  and 
legs  and  thighs  flexed  to  the  degree  of  affording  most  relaxation  to  the 
abdominal  muscles. 

Bimanual  palpation  gives  information  not  only  as  to  the  size,  shape, 
mobility  and  position  of  the  uterus,  but  often  gives  valuable  informa- 
tion regarding  the  bladder  and  ureters:  As  to  whether  they  are  thick- 
ened, tender,  severely  inflamed,  etc.;  and  sometimes  a  ureteral  stone 
may  be  felt  in  the  lower  part  of  the  ureter. 

Bimanual  palpation  of  the  kidneys  should  be  made  with  the  patient 
in  three  successive  positions :  Lying  down,  semireclining  and  standing 
up.  These  changes  give  opportunity  of  detecting  the  mobility  of  loose 
kidneys  as  well  as  outlining  the  shape  and  size  of  the  organs,  and  elicit- 
ing any  tenderness  that  may  be  present. 

BIBLIOGRAPHY. 

1.  Guiteras:  Urology,  i. 

2.  Kummel:  Trans.  32d  Congress  of  German  Surg.  Soc. 

3.  Lewis:  Ann.  Surg.,  March,  1915. 

4.  Lewis:  Keen's  Surg.,  iv,  300. 

5.  Lewis:  Trans.  Am.  Assn.  of  Genito-Urin.  Surg.,  1893. 

6.  Lewis  and  Mark:  Cystoscopy  and  Urethroscopy,  1915. 

7.  Schmidt  and  Kretchmer:  Trans.  Am.  Urolog.  Assn.,  1911,  p.  233. 

8.  Schwarz  and  McNeil:  Am.  Jour.  Med.  Sc.,  May,  1911. 

9.  Thomas:  Jour.  Am.  Med.  Assn.,  November  28,  1914. 


CHAPTER  IV. 
THE  ROENTGENOLOGY  OF  THE  URINARY  TRACT. 

BY  WALTER  J.  DODD,  M.D. 

IN  order  to  make  a  successful  examination  of  the  urinary  tract, 
certain  conditions  are  necessary.  The  patient  must  be  prepared  and 
the  proper  technic  used.  It  is  absolutely  essential  that  a  distinct  out- 
line of  both  kidneys  should  be  seen  and  the  entire  course  of  the  ureter 
and  bladder  must  also  be  examined.  It  has  been  stated  that  a  good 
.r-ray  plate  must  show  the  transverse  processes  of  the  lumbar  vertebra, 
the  eleventh  and  twelfth  ribs  and  outline  of  the  psoas  muscle.  Some 
years  ago,  roentgenologists  had  to  be  content  with  the  above,  but  today 
there  is  no  reason  why  a  distinct  outline  of  both  kidneys  cannot  be 
clearly  revealed,  even  in  stout  individuals. 

Preparation  of  Patient.— When  possible,  the  patient  should  be  given 
a  good  cathartic,  preferably  a  sufficient  dose  of  castor  oil,  and  for 
twenty-four  hours  preceding  the  examinations  liquids  without  solids 
should  be  the  diet.  Enemata  should  be  given  only  in  emergencies, 
owing  to  the  fact  that  particularly  if  there  is  much  delay  before  the 
examination  is  made,  the  intestines  are  apt  to  become  distended  with 
gas  and  the  kidney  outlines  may  be  obliterated.  Calomel  or  prepara- 
tion containing  heavy  metalic  salts  should  not  be  used  as  a  cathartic. 

The  above  conditions  we  realize  are  ideal  and  frequently  cannot  be 
followed.  In  fact,  hundreds  of  cases  are  examined  every  year  in  a 
large  out-patient  clinic  and  the  known  error  is  still  only  5  per  cent. 

It  would  seem  from  this  that,  if  a  thorough  technic  on  the  part 
of  the  roentgenologists  is  complied  with,  the  Roentgen  examination  of 
the  urinary  tract  for  the  detection  of  urinary  calculi  must  be  considered 
extremely  successful. 

Under  ideal  conditions,  roentgenologists  agree  that  probably  2  per 
cent,  would  be  an  excusable  error.  We  must  remember  that  there  are 
certain  types  of  renal  calculi,  fortunately  extremely  rare,  such  as 
zanthin,  cystin,  and  pure  uric  acid  calculi,  which  are  detected  only 
with  great  difficulty.  Pure  uric  acid  calculi  are  rare  in  adults. 
Although  many  have  been  reported  as  being  revealed  by  the  Roentgen 
methods,  if  a  perfect  chemical  analysis  had  been  made  of  these  stones, 
enough  calcium  salts  would  have  been  found  present  to  explain  the 
reason  of  their  detection  by  this  method. 

Sources  of  Error. — It  has  been  stated  by  various  writers  that  the 
percentage  of  error  in  locating  renal  calculi  varies  from  5  to  over  30 
per  cent.  Five  per  cent,  is  almost  an  excusable  error  in  a  large  out- 
patient clinic  where  the  patients  are  not  properly  prepared  and  are 

(147) 


148          THE  ROENTGENOLOGY  OF   THE   URINARY   TRACT 

often  apprehensive  and  many  times  cannot  be  made  to  understand  the 
very  essential  point  that  they  must  hold  their  breath  during  the  exposure. 


FIG.  92. — Patient  sent  in  for  examination  of  spine.  Old  Pott's  disease.  Plate 
reveals  stone  in  kidney.  This  plate  shows  the  great  importance  of  not  only  examining 
spine  in  such  cases,  but  also  the  renal  area.  It  is  also  wise  to  examine  spine  when 
making  renal  examination,  as  not  infrequently  pathological  processes  may  be  revealed 
in  the  spine. 


FIG.  93. — Stone  in  the  pelvis  of  the  kidney.  No  symptoms.  Patient  sent  in  for 
other  examination.  X-ray  examination  of  kidney  made  owing  to  presence  of  pus  in 
urine. 


SOURCES  OF  ERROR 


149 


\  Cry  frequently  calcified  glands  are  present.      Sometimes  singly 
and,  in  other  cases,  numerous  glands  are  seen.     As  a  rule,  it  is  easy  to 


BB 


FIG.  94. — Shadows  seen  over  fifth  lumbar  transverse  j >!<><• 
catheter  to  he  calcined  glands. 


>roved  by  radirtyraphic 


distinguish  between  calcified  glands  and  renal  calculi.  The  writer  has 
found  that  the  best  method  to  differentiate  these  shadows  from  calculi 
was  to  take  separate  plates,  one  in  forced  inspiration  and  the  other  in 


Fie.  95. — Radiographic  catheter  proves  that  shadow  seen  over  fifth  lumbar  transverse 

process  is  not  in  ureter. 


forced  expiration.     Usually  it  will  be  seen  that  the  shadow  does  not 
bear  the  same  relation  to  the  kidney  in  these  two  plates,  as  the  kidney 


150 

probably  moves  to  a  much  less  degree  than  the  glands.     Stereoscopic 
plates  are  also  of  great  value  in  such  cases. 

Pigmented  Moles. — Pigmented  moles  on  the  back  of  the  patient, 
which  sometimes  lie  in  the  course  of  the  ureter  or  in  the  renal  area, 
may  also  be  mistaken  for  calculi.  Here,  again,  stereoscopic  plates 
would  be  of  greatest  value,  or  if  a  wire  ring  is  put  around  the  mole  and 
a  piece  of  adhesive  plaster  fastened  over  the  ring  on  the  skin,  it  will 
be  seen  that  the  shadow  changes  its  position.  When  the  adhesive  strap 
is  pulled  to  one  side,  its  relation  to  the  transverse  processes  of  the 
lumbar  vertebra  may  be  changed  considerably. 


FIG.  96. — Large  phlcbolith  adherent  to  the  ureter  causing  symptoms. 
(Case  of  Dr.  Lincoln  Dodge.) 

Concretions  in  the  Appendix. — These  may  be  mistaken  for  ureteral 
calculi,  particularly  following  a  bismuth  meal. 

Osteophytes. — Osteophytes  of  the  transverse  processes  of  the  lumbar 
vertebrae  not  infrequently  look  like  small,  round  ureteral  calculi,  but 
ureteral  catheters  impervious  to  the  x-rays  and  stereoscopic  plates 
will  enable  one  to  readily  differentiate  this  shadow  from  a  calculus. 

Phleboliths.— Phleboliths  which  are  so  frequently  found  in  the  large 
veins  of  the  pelvis,  and  oftentimes  lie  right  in  the  course  of  the  ureter, 
can  invariably  be  distinguished  by  means  of  the  ureteral  catheter  and 
stereoscopic  plates. 

Intestine  Shadows. — Intestine  shadows,  as  a  rule,  can  be  readily 
recognized,  but  not  infrequently  small  masses  of  bismuth,  following  a 


SOURCES  OF  ERROR 


151 


bismuth  meal,. may  lie  in  the  renal  area  or  in  the  course  of  the  ureter. 
As  a  rule,  however,  these  shadows  are  of  such  a  nature  that  this  need 


FIG.  97. — Numerous  stones  in  right  kidney.     Might  be  mistaken  for  gall-stones. 
One  large  stone  in  left. 

not  be  considered  a  serious  source  of  error.     Calomel  tablets  or  other 
pills  or  tablets  containing  heavy  metal  salts  may  give  rise  to  mistakes. 


FIG.  98. — Same  case  after  removal  of  stones  from  right  kidney. 


Gall-stones. — Gall-stones  not  infrequently  closely  resemble  renal 
calculi  and  may  lie  in  the  renal  area.    As  a  rule  the  shadow  changes  its 


Io2  THE   ROENTGEXOLOdY   OF    THE    I'RIXARY   TRACT 

relation  in  full  inspiration  and  forced  expiration  more  than  the  kidney 
outline  changes.  The  best  way  to  differentiate  gall-stones  from  renal 
stones,  however,  is  to  take  a  plate  of  the  patient  in  the  prone  position 
as  well  as  in  the  supine  position.  In  the  prone  position  the  shadows 
will  appear  much  clearer  than  when  in  the  supine  position. 

Technic. — We  have  seen  that  a  good  Roentgen  plate  of  the  urinary 
tract  must  show  the  outline  of  both  kidneys,  as  well  as  the  transverse 
processes  of  the  lumbar  vertebrae,  psoas  muscle,  and  the  eleventh  and 
twelfth  ribs,  and  that  part  of  the  bones  of  the  pelvis,  i.  e.,  sacrum  and 
ilium,  which  the  ureter  crosses.  In  order  to  obtain  such  a  plate,  cer- 
tain points  of  technic  must  be  observed,  and  as  already  stated,  if  pos- 
sible, the  patient  should  be  properly  prepared. 


FIG.  99. — Multiple  renal  calculi  in  boy,  aged  eleven  years. 

For  a  number  of  years  the  writer  has  used  a  pure  rubber  bag  covered 
with  canvas  in  order  to  get  the  necessary  compression.  Some  form  of 
compression  must  be  used.  The  compression  cylinder  is  extremely 
valuable,  but  he  has  found  the  rubber  bag,  first  suggested  by  Cald- 
well,  far  superior.  The  compression  when  applied  by  this  means  is 
more  bearable  to  the  patient  and  is  more  uniform.  Small -compression 
cylinders  can  be  used  and  separate  plates  taken  of  each  kidney:  one  of 
the  middle  portion  of  the  ureter  and  another  plate  of  the  lower  portion 
of  the  ureter  and  bladder.  He  has  found,  however,  that  both  kidney 
outlines  can  be  distinctly  seen  on  one  plate  when  the  proper  compres~ 
sion  is  applied  with  the  inflated  rubber  bag,  and  that  another  plate 


TECHN1C 


153 


taken  of  the  lower  portion  of  the  ureter  and  bladder  will  give  the  entire 
urinary  tract. 

Thus  it  is  necessary  to  take  only  three  plates :  two  of  the  renal  area, 
one  in  forced  expiration  and  one  in  forced  inspiration,  and  another  one 
of  the  bladder  and  the  lower  portion  of  the  ureter. 

After  the  plate  is  properly  under  the  patient,  making  sure  that  the 
top  of  the  plate  is  at  least  as  high  as  the  tenth  rib  and  the  lower  edge 
of  the  plate  is  just  below  the  crest  of  the  ilium,  the  tube  is  carefully 
f ocussed  in  the  median  line ;  the  compression  bag  or  cylinder  is  then 
placed  on  the  abdomen ;  the  patient  is  requested  to  take  a  long  breath 


FIG.  100. — Illustrating  position  of  patient  when  taking  plate  of  kidney.  Notice  that 
the  shoulders  and  legs  are  elevated  and  that  the  back  is  flat  on  plate.  Patient's  arm 
elevated  to  show  plate.  Should  be  at  the  side  when  plate  is  taken. 


and  slight  compression  is  applied.  The  cylinder  or  bag  will  thus  be 
forced  down  slightly  under  the  costal  margin  and  the  focal  point  of 
the  tube  will  be  practically  between  the  ensiform  and  the  umbilicus. 
The  patient  is  requested  to  take  another  full  breath  and  then  forcibly 
exhale  it.  When  the  lungs  are  completely  empty,  full  compression  is 
applied.  The  tube  is  locked  in  place  after  being  tilted  upward  about 
5  degrees  so  that  the  central  rays  cut  upward,  thus  enabling  one  to 
get  a  picture  of  the  upper  portion  as  well  as  the  rest  of  the  kidney 
outline.  The  legs  are  flexed  in  order  to  correct  the  lordosis  which  is  so 
commonly  present,  thus  bringing  the  back  of  the  patient  close  to  the 


154 


THE  ROENTGENOLOGY  OF  THE  URINARY  TRACT 


plate.  When  necessary,  the  shoulders  are  elevated.  The  elevation  of 
the  shoulders  and  flexion  of  the  legs  should,  of  course,  be  done  before 
compression  is  applied. 

After  these  essentials  are  complied  with,  it  is  only  necessary  to 
make  the  exposure,  but  the  patient  should  be  instructed  not  to 
breath  during  the  exposure  and  to  keep  perfectly  still.  The  length 
of  the  exposure  varies  from  a  fraction  of  a  second  to  two  seconds, 
according  to  the  size  of  the  patient.  After  this  exposure  has  been  made, 
another  plate  is  taken  in  forced  inspiration.  The  third  plate  of  the 
lower  portion  of  the  ureter  and  bladder  is  now  taken.  Compression 


FIG.  101. — Position  of  tube  when  plate  of  bladder  and  lower  portion  of  ureter  is  taken. 


cylinder  with  the  rubber  bag  can  be  used.  The  focal  point  for  this 
plate  should  be  exactly  in  the  median  line  of  the  body  and  the  central 
rays  should  pass  through  a  point  just  below  the  anterior  superior  spine, 
but  always  in  the  median  line.  This  will  give  us  that  portion  of  the 
bony  pelvis  and  the  sacral  synchondrosis  over  which  the  ureter  passes, 
as  well  as  the  bladder.  The  tube  should  be  tilted  about  10  degrees. 
Not  infrequently  ureteral  stones  lie  in  the  ureter  as  it  crosses  the  sacrum 
and  may  lie  right  at  the  brim  of  the  pelvis.  A  good  plate  will  usually 
show  these  calculi  even  without  tilting  the  tube,  but  if  the  stone  is  not 
sufficiently  dense,  it  may  be  overlooked  unless  the  tube  is  tilted. 


PYELOGRAPHY 


155 


Stones  near  the  brim  of  the  pelvis  with  this  technic  will  be  thrown  off 
the  bony  structures  and  the  shadows  appear  in  the  true  pelvis. 

Pyelography. — This  term  has  been  applied  to  that  part  of  roentgen- 
ography  in  which  the  pelvis  of  the  kidney  and  ureter  is  made  apparent 
on  the  plates  by  injecting  into  the  renal  pelvis  some  solution  that  is 
opaque  to  the  .r-rays,  such  as  collargol,  solution  of  thorium  nitrate  or  a 
suspension  of  argentide.  The  writer  has  found  the  argentide  suspension 
very  satisfactory  and  not  so  irritating  as  a  collargol  solution. 

This  method  is  of  extreme  importance  in  some  cases,  for  when  the 
renal  pelvis  is  properly  injected,  abnormalities  in  contour  as  well  as  size 
can  be  quite  readily  determined. 


FIG.  102. — Collargol  injection  showing  evidence  of  renal  tumor, 
distorted.     Kidney  lower  than  normal. 


Pelvis  large  and 


Uric  Acid  Stones. — Another  valuable  use  of  this  method  is  in  cases 
where  clinical  evidence  points  very  positively  to  the  presence  of  a  stone 
and  the  stone  has  not  been  revealed  on  the  .r-ray  plate,  the  injection  of 
an  opaque  solution  will  frequently  coat  the  stone  which  by  the  ordinary 
method  was  invisible.  The  writer  believes  that  when  such  stones  are 
revealed  by  this  method,  that  they  are  probably  pure  uric  acid  or  stones 
that  do  not  contain  sufficient  lime  to  demonstrate  their  presence. 

Nephroptosis. — Another  use  for  the  opaque  solution  is  to  determine 
whether  the  patient  has  a  very  freely  movable  kidney.  This  is  best 
determined  by  taking  the  regular  compression  picture  and  then  without 
shifting  the  position  of  the  tube  in  relation  to  the  patient,  simply  with- 
draw the  original  plate,  insert  a  fresh  one,  and  then  tip  the  table  into 
the  upright  position;  an  exposure  being  made,  of  course,  in  this  position. 

This  technic  requires  a  special  table  and  it  is  better  to  use  one  in 


156 


THE  ROENTGENOLOGY  OF  THE   URINARY   TRACT 


which  the  tube  is  under  the  table  and  moves  with  the  table  as  it  is 
tipped.  This  requires  that  the  patient  be  in  the  prone  position  instead 
of  in  the  supine  position.  This  is  an  extremely  valuable  method  and 


FIG.  103. — C'ollar-rol  injection  showing  kink  in  ureter. 


FIG.  104. — Stone  in  ureter. 


PYELOGRAPHY 


157 


FIG.  105. — Large  stone  in  ureter.     Removed  by  Dr.  Horace  Binney. 


FIG.  106. — Ureteral  calculi — one  at  vesicle  orifice  and  one  just  above  the  bladder. 


158 


THE  ROENTGENOLOGY  OF  THE   URINARY  TRACT 


FIG.  107. — Same  case  eighteen  hours  later.  Very  important,  as  this  case  shows,  the 
great  necessity  of  making  the  examination  as  near  the  time  of  operation  as  possible,  as 
the  stones  may  change  their  position. 


FlG  108  _stone  in  left  ureter  appears  just  below  brim  of  pelvis.  Was  not  revealed 
in  original  plate  which  was  uot  clear  enough  to  differentiate  the  stone  from  the  bony 
structures. 


PYELOGRAPHY 


159 


fluoroscopy  can  be  combined  with  roentgenography  in  such  cases  with 
such  a  table. 

Ureteral  Calculi. — The  use  of  the  opaque  solution  in  determining 
the  presence  of  ureteral  calculi  is  also  of  value.  When  the  roent- 
genologist  makes  the  diagnosis  of  a  stone  in  the  ureter  or  when  the 
diagnosis  is  doubtful  owing  to  the  presence  of  phleboliths  or  calcified 
glands  or  shadows  in  the  region  of  the  appendix,  this  method  will  fre- 
quently give  confirmatory  evidence.  It  is  not  at  all  uncommon  for  the 
catheter  to  pass  freely  through  the  entire  course  of  the  ureter  without 
obstruction  even  when  a  stone  is  present,  as  the  ureter  may  be  greatly 
dilated. 


FIG.  109. — Large  prostatio  calculus  weighing  60  grams. 

When  the  opaque  solution  is  injected,  the  stone,  as  a  rule,  will  be 
surrounded  by  the  collargol  shadow.  The  opaque  solution  also  is  of 
great  use  in  revealing  kinks  and  tortuosities  of  the  ureter. 

Prostatic  Calculi.— The  same  technic  is  used  as  was  described  tor 
stones  in  the  lower  portion  of  the  ureter  and  bladder.  That  is,  the 
tube  is  tilted  from  5  to  10  degrees,  the  focus  of  the  tube  being  in  the 
median  line,  midway  between  the  symphysis  and  the  anterior  superior 
spine.  This  will  throw  the  symphysis  off  the  field  and  prostatic  calculi 
may  be  revealed  providing  they  contain  sufficient  lime  salts. 


160          THE  ROENTGEXOLOGY  OF   THE   L'RIXARY   TRACT 

Diverticula. — Another  use  for  the  opaque  solution  is  in  demonstrating 
cliverticula  of  the  bladder.  The  writer  has  found  the  best  method  to  be 
the  following:  About  one  ounce  of  a  20  per  cent,  solution  of  collargol  is 
injected  into  the  bladder  and  allowed  to  remain  for  a  few  minutes.  The 
bladder  is  then  evacuated  and  in  most  cases  the  diverticuli  will  retain 
sufficient  solution  to  be  well  defined  on  the  plates. 

Stone  in  the  Bladder. — Most  stones  in  the  bladder  can  be  readily  re- 
vealed, but  soft  phosphatic  stones  are  not  infrequently  missed.  If  the 
bladder  is  distended,  a  distinct  outline  can  usually  be  seen,  but  the 
stone  itself  may  appear  very  faint.  In  such  cases  it  is  wise  to  have  the 
bladder  evacuated  and  take  another  plate.  Xot  only  will  the  stone 
appear  more  distinct  but  not  infrequently  its  position  will  have  changed. 

Faint  shadows  often  appear  in  the  region  of  the  bladder  and  these 
shadows  are  usually  due  to  intestinal  contents.  Calcification  in  the 
walls  of  the  uterus  may  resemble  a  stone,  also  calcification  of  the  ovary. 
As  a  rule  these  sources  of  error  can  be  readily  eliminated.  The 
intestinal  contents  can  be  eliminated  by  means  of  an  enema  and  the 
shadows  in  the  uterus  and  ovaries  by  palpation. 

Exposure. — The  length  of  the  exposure  depends  upon  two  factors:  the 
power  of  the  machine  and  the  size  of  the  patient.  In  such  an  article 
as  this  it  is  unnecessary  to  go  into  details  regarding  apparatus.  It  is 
only  necessary  to  say  that  with  the  modern  transformer,  so-called 
interrupterless  machines,  the  exposure  varies  from  one-half  second  to 
four  seconds,  according  to  the  size  of  the  patient.  The  penetration 
of  the  tube  should  be  equivalent  to  6  or  7  degrees  on  the  Benoit 
penetrometer. 

Dark-room  Technic. — Absolute  cleanliness  in  the  dark-room  is  essen- 
tial and  nothing  should  come  in  contact  with  the  film  of  the  plate.  The 
author  has  found  the  tank  system  of  developing  the  ideal  method.  The 
formulae  for  developing  and  the  fixing  solutions  are  usually  furnished 
by  the  plate  manufacturer,  any  of  which  are  perfectly  satisfactory. 

A  normal  plate  will  be  developed  in  from  six  to  ten  minutes.  It 
should  be  thoroughly  washed  in  running  water  before  being  placed  in 
the  fixing  bath.  It  is  wise,  as  a  rule,  to  leave  the  plate  in  the  fixing 
bath  for  about  fifteen  minutes  after  all  signs  of  unaffected  silver  salts 
have  disappeared.  Otherwise  the  plates  will  slowly  become  blackened 
and  the  image  almost  disappear.  The  plates  should,  of  course,  be 
thoroughly  washed  in  running  water  for  about  one-half  hour  and 
interpreted  when  dry. 


CHAPTER  V. 
SYPHILIS  OF  THE  GENITO-URINARY  ORGANS. 

BY  B.  C.  CORBUS,  M.D. 

SYPHILIS  OF  THE  URETHRA. 

THE  Spirochaeta  pallida  may  invade  the  urethra  in  either  the  primary, 
secondary,  or  tertiary  periods,  and  provoke  lesions  which  on  account 
of  their  site,  form,  and  evolution  may  produce  a  variety  of  more  or  less 
obscure  symptoms. 

In  1897  appeared  the  first  review  of  syphilis  of  the  urethra,  by 
Faitout,5  followed  later  (1898)  by  the  thesis  of  Bellet,22  and  still 
later  (1905)  by  the  general  review  of  "Syphilis  of  the  Urethra,"  by 
Simionescu.15  More  recently  (1908)  the  thesis  of  Rougier,14  "Tertiary 
Syphilis  of  the  Urethra,"  followed  by  the  general  review  of  "  Syphilis  of 
the  Urethra,"  by  Tanton/6  have  added  materially  to  our  knowledge  of 
these  conditions. 

Primary  Syphilis. — 1.  Frequency. — Fournier8  reports  that  out  of  414 
indurated  chancres,  32  occurring  at  the  meatus,  17  were  deep  and  could 
easily  have  escaped  notice.  In  women  urethral  chancre  is  much  more 
infrequent  than  in  men.  According  to  Fournier,7  the  order  of  frequency 
in  women  is  as  follows :  Entrance  to  the  vagina,  region  of  the  clitoris, 
uterine  neck,  and  urethra. 

2.  Location. — Urethral  chancre  is  located  either  at  the  meatus 
(chancre  of  the  meatus)  or  more  deeply  in  the  interior  of  the  urethral 
canal  (end o- urethral  chancre). 

A.  CHANCRE  OF  THE  MEATUS. — Chancre  of  the  meatus  may  make 
its  appearance  in  the  following  w'ays: 

1.  Round  chancre  embraces  all  of  the  free  extremity  of  the  canal. 
This  form  presents  itself  under  the  aspect  of  a  small  rose-colored  circle, 
hemming  in  the  meatus  and  leaving  the  urethra  projecting  like  a  beak 
on  the  surface  of  the  glans. 

2.  Left  or  right  hemilateral  chancre  occupies  the  corresponding  lip 
of  the  meatus;  it  appears  under  the  form  of  a  projecting  nodule  which 
provokes  a  deformation  of  the  meatus  by  retraction  of  the  correspond- 
ing lip  or  side  on  which  the  chancre  is  located. 

3.  Superior  or  inferior  commissural  chancre  occurs  in  the  form  of  a 
crescent,  the  corners  of  which  descend  or  ascend  more  or  less  on  either 
of  the  two  lips  of  the  meatus  or  on  both. 

These  three  types  of  chancre  during  the  course  of  their  evolution 
may  lose  the  primitive  characteristics  which  differentiate  them  from 
each  other,  particularly  when  phagedena  is  a  complication. 

MU      I— 11  (161) 


102  XYI'lULIX  OF  THE  GEN  I  TO-URINARY  ORGANS 

Symptoms.  -  -Syphilitic  chancre  of  the  meatus  may  be  of  either 
erosive  or  ulcerative  type.  Induration  is  marked  and  often  diffuses 
toward  neighboring  structures. 

^  hen  the  chancre  is  situated  exactly  on  the  meatus,  whether  or  not 
it  extends  itself  into  the  canal,  the  orifice  presents  itself  as  swollen, 
deformed,  red  and  gaping,  bleeding  on  pressure  and  offering  to  the 
touch  a  sharply  circumscribed,  indurated  area. 

In  women,  syphilitic  chancre  of  the  meatus  usually  has  its  site  at  the 
inferior  angle  of  the  orifice.  Simionescu15  cites  an  observation  where 
the  chancre,  primarily  located  at  the  meatus,  sank  into  the  urethra  up 
to  the  vesical  neck. 

B.  ENDO-UBETHRAL  CHANCRE. — While  endo-urethral  chancre  is  not 
common,  it  is  far  from  uncommon.  Occurring  in  the  fossa  navicularis 
portion  of  the  urethra,  as  it  does,  many  times  it  is  unrecognized.  Often 
it  is  so  near  the  meatus  that  it  can  be  seen  by  forcibly  separating  the 
borders  of  the  urethral  orifice.  Du  Castel4  observed  one  situated  2 
cm.  behind  the  fossa  navicularis.  Fasoli6  cites  one  situated  2|  cm. 
from  the  meatus  on  the  inferior  wall  of  the  urethra. 

Endo-urethral  chancre  occurs  in  the  following  ways: 

1.  From  a  chancre  at  the  meatus,  extending  by  continuity.     The 
endo-urethral  chancre  of  the  anterior  portion  of  the  urethra  is  only  an 
extension  of  the  chancre  of  the  meatus. 

2.  Sometimes,  in  patients  afflicted  with  gonorrhea,  the  mucous  mem- 
brane in  the  fossa  navicularis  becomes  erodeda  producing  an  atrium  of 
entrance  for  the  spirochetes. 

3.  It  is  possible,  but  highly  improbable,  that  infection  may  take  place 
by  the  passage  of  sounds  into  the  urethra.     Such  things  have  been 
reported,  but  in  this  day  of  asepsis  and  antisepsis,  it  is  almost  beyond 
belief. 

Ki/DiptoiHx. — The  three  principal  symptoms  are: 

1.  Pain. 

2.  Discharge. 

3.  Induration. 

1.  Pain. — This  is  slight,  always  accompanies  micturition  and  occurs 
in  the  majority  of  cases  toward  the  end  of  urination ;  this  is  due  to  the 
expansion  and  contraction  of  the  base  of  the  lesion. 

2.  Discharge.  —  This  is  the  first  symptom  noticed  by  the  patient 
and  causes  him  to  consult  a  physician.     In  every  case  a  discharge  is  the 
initial  symptom.     It  begins  slowly  after  variable  periods  of  incubation. 
In  the  beginning  it  is  seldom  accompanied  by  pain  at  the  time  of  mic- 
turition; it  is  very  watery  at  first,  later  slightly  seropurulent,  easily 
becoming  blood-tinged,  especially  if  the  urethra  is  palpated  roughly. 
At  times  the  discharge  is  thick  and  purulent,  but  this  is  always  a  sign 
of  mixed  infection. 

3.  Induration. — This  is  perceptible  only  by  palpating  the  glans  from 
behind  and  in  front;  the  chancre  is  situated  in  the  substance  of  the 
urethra,  following  an  anterior-posterior  direction,  and,  as  a  consequence, 
is  lamellate  in  form.     Often  in  the  fossa  navicularis  the  induration 


SYPHILIS  OF  THE   URETHRA  163 

manifests  itself  as  a  mass  of  cartilaginous  consistency  and  of  variable 
dimensions. 

In  women  the  endo-urethral  chancre  is  situated  in  the  anterior  part 
of  the  canal;  in  order  to  locate  the  induration,  the  index  finger  of  the 
left  hand  is  introduced  into  the  vagina  in  contact  with  the  suburethral 
region,  while  the  right  index  finger  examines  the  meatus  from  before 
backward.  Sometimes  this  forms  a  veritable  indurated  cylinder,  a  peri- 
urethral  muff,  around  the  canal.  At  other  times  it  is  limited  to  the 
inferior  segment  of  the  canal  and  to  the  lateral  surfaces. 

Syphilitic  chancre  of  the  urethra  is  accompanied  by  indolent  inguinal 
adenitis,  the  same  as  any  other  chancre  situated  on  the  penis;  at  times 
the  dorsal  lymphatic  vessels  appear  as  an  indurated  cord. 

Diagnosis. — Chancre  of  the  meatus  should  not  be  difficult  of  diagnosis 
from  the  character  of  the  induration,  appearance,  and  lastly  and  most 
important,  from  the  microscopic  examination  of  the  secretion  for 
Spirochseta  pallida. 

In  endo-urethral  chancre,  most  patients  present  themselves  on 
account  of  a  discharge;  this  should  be  immediately  examined  for 
gonococci,  as  this  is  the  most  frequent  condition  that  produces  a  "ure- 
thral  running."  Failure  to  find  any  organism  either  of  a  specific  or 
non-specific  variety  should  arouse  suspicion. 

Chancre  of  the  meatus  may  be  confounded  with  simple  chancroid 
of  the  meatus,  on  account  of  induration  caused  by  the  irritating  effect 
of  the  urine;  however,  in  chancroid  there  is  more  discharge  and  extreme 
pain,  and  the  lesion  may  be  covered  by  a  membrane  with  a  dirty,  moth- 
eaten  appearance. 

Superficial  erosions  due  to  gonorrhea  may  simulate  chancre  of  the 
meatus,  or  both  may  exist  together. 

Herpetic  eruptions  are  multiple,  the  borders  are  polycyclic,  and, 
if  recent  (vesicle  stage),  clear  serum  can  be  expressed  from  the 
lesion. 

Syphilitic  chancre  of  the  meatus  may  be  confounded  with  epithelioma 
of  the  glans;  here  an  error  in  diagnosis  might  lead  to  unnecessary 
operation.  The  epithelioma  may  be  accompanied  by  infiltration  and 
adenopathy,  the  same  as  a  chancre. 

In  women  the  error  may  be  still  more  easy,  as  the  periphery  of  the 
meatus  is  the  place  of  election  of  urethral  epithelioma;  cancerous 
induration  is  more  extended,  but  less  hard  and  less  resistant  than  the 
syphilitic  induration.  The  adenopathy  is  less  tardy  in  the  neoplasm, 
and  the  neoplasm  does  not  tend  toward  cicatrization. 

However,  in  all  cases  a  careful  history  should  be  noted,  together  with 
a  complete  physical  and  careful  microscopic  examination.  In  examin- 
ing for  Spirochseta  pallida  there  is  no  better  way  of  obtaining  the 
material  than  by  capillary  attraction,  as  illustrated  on  page  251,  under 
Genital  Ulcers. 

Complications. — The  evolution  of  urethral  chancre  is  slower  than  that 
of  other  syphilitic  chancres;  this  is  due,  in  a  measure,  to  the  constant 
passage  of  urine  and  secondary  infection,  with  poor  drainage. 


164  SYPHILIS  OF   THE   (iEMTO-UKIX ARY  O/.Y/.l.YN 

Ukeration. — Often  in  the  male  and  female,  syphilitic  chancres  of  the 
meatus  may  form  extensive  ulcerations,  the  edges  become  uneven,  the 
base  grayish,  and  a  pseudomembrane  may  form,  giving  the  condition, 
as  a  whole,  a  formidable  appearance. 

Phayedena. — Occasionally,  in  practice,  more  especially  in  dispensary 
work,  chancre  of  the  meatus  isseen  complicated  by  phagedena.  This 
condition,  occurring  in  endo-urethral  lesions,  is  not  so  common.  When 
occurring  at  the  meatus,  it  may  form  extensive  cavities,  extending 
deeply;  it  may  even  decapitate  the  glans  penis  or  enlarge  the  meatus 
considerably.  Extensive  mutilation  may  later  cause  complete  closure 
of  the  orifice,  calling  for  surgical  interference. 

Strictiiir. — Chancre  of  the  meatus  or  endo-urethral  chancre  may  at 
times  cause  stricture.  Two  varieties  may  occur: 

1.  A  diminution  of  the  caliber  due  to  the  syphilomatous  neoplasm. 

2.  True  cicatricial  stenosis. 

The  first  variety  occurs  at  the  time  of  the  specific  induration  and  is 
of  little  importance;  the  stenosis  disappears  with  the  reabsorption  of 
the  induration. 

The  second  variety  follows  ulcerated  or  phagedenic  chancres,  espe- 
cially of  the  meatus  and  fossa  navicularis.  These  strictures  follow 
the  general  law  of  cicatricial  strictures.  They  develop  with  great 
rapidity  and  offer  great  resistance  to  dilatation. 

Secondary  Syphilis.  —  Urethral  Mucous  Syphilides.  —  Numerous 
French  authors  recognize  the  possible  existence  of  a  specific  secondary 
urethritis.  It  is  characterized  by  a  more  or  less  viscous,  transparent, 
slightly  opalescent  discharge,  rarely  creamy  or  purulent.  This  is  scarcely 
perceptible  during  the  day,  but  is  always  present  in  the  morning, 
after  the  urine  has  been  held  all  night.  Inflammatory  symptoms  are 
absent.  Microscopic  examination  without  the  dark-field  condenser 
shows  nothing  characteristic;  mucus  and  epithelial  cells  predominate. 
However,  the  Spirocha?ta  pallida  may  be  found  if  the  proper  appa- 
ratus is  used.  Antisyphilitic  treatment  rapidly  clears  up  the  con- 
dition. 

It  is  this  secondary  specific  urethritis  that  is  the  means  of  contagion 
through  the  semen,  which,  during  this  period,  in  its  passage  through  the 
urethra  at  the  time  of  ejaculation  becomes  saturated  with  the  urethral 
discharge  and  the  spirochetes  that  it  contains,  thus  acting  as  a  carrier 
of  the  infection. 

An  interesting  case  of  Rochon  is  cited  by  Tanton,15  the  details  of 
which  are  as  follows :  A  woman  presented  on  the  abdomen  excoriations 
caused  by  her  corset;  the  syphilitic  husband,  afraid  of  having  syphilitic 
children,  had  the  habit  of  ejaculating  on  the  abdomen.  A  gigantic 
chancre  developed  at  the  site  of  the  excoriations.  The  author  con- 
cluded that  urethral  mucous  syphilides  existed. 

Tertiary  Syphilis. — In  1901  Fournier8  reported  nineteen  cases  of 
tertiary  syphilis  of  the  urethra;  Mauriac,11  Gaudier,10  Renault,12  and 
Rougier"  have  observed  and  reported  cases;  recently  Drs.  Dey  and 
Kirby-Smith3  in  this  country  have  reported  two  interesting  cases. 


SYPHILIS  OF  THE   URETHRA  165 

Time  of  Appearance. — Often  they  are  late,  making  their  appearance 
eight,  ten,  or  even  fifteen  to  twenty  years  after  the  primary  symp- 
toms. 

Modes  of  Invasion. — 1.  Primary. — These  lesions  make  their  appear- 
ance by  way  of  the  canal. 

2.  Secondary. — These  lesions  appear  in  the  canal  from  an  extension 
by  continuity. 

In  the  case  of  primary  localization  these  lesions  may  appear  under 
two  forms. 

(a)  Primary  ulceration. 
(6)  Syphilitic  gumma. 

The  latter  is  the  most  common  form  and  may  be  presented  under  two 
clinical  aspects : 

1.  Circumscribed  infiltration. 

2.  Diffuse  infiltration. 

Circumscribed  infiltration  appears  as  a  small  gummatous  tumor, 
often  resembling  a  small  tumor  or  core,  forming  a  slightly  rounded  or 
hemispherical  projecture. 

In  the  diffuse  infiltration  the  gumma  grows  on  the  surface,  infil- 
trating the  tissues  to  a  variable  extent,  often  appearing  as  a  sheet-like 
induration. 

Both  of  these  forms  may  contract  the  canal,  causing  symptoms  of 
obstruction  in  a  greater  or  less  degree.  However,  these  forms  often 
undergo  softening  and  ulceration,  thereby  eliminating,  for  the  time 
being,  obstructive  symptoms.  Hemorrhage  following  such  a  condition 
may  be  severe. 

These  gummata  may  break  down  and  ulcerate  in  either  one  of  two 
ways:  toward  the  urethral  canal  or  on  the  under  surface.  If  the 
gumma  breaks  down  on  the  surface  which  is  in  connection  with  the 
urethral  canal,  it  often  forms  internal  blind  fistulae  which  act  as 
reservoirs  and  collect  urine  during  the  act  of  micturition.  Later,  these 
foci  may  be  the  starting-points  of  urinary  infiltration  and  abscess. 

Symptoms. — Tertiary  syphilitic  lesions  of  the  urethra  have  the  fol- 
lowing characteristics: 

1.  Insidious  invasion,  indolent,  often  remaining  for  a  long  time 
unnoticed. 

2.  Slow  evolution :  It  is  necessary  for  these  lesions  to  attain  compara- 
tively large  proportions  before  the  patient  seeks  surgical  advice. 

3.  The  local  reaction  is  generally  insignificant  or  absent.     There  is  no 
inguinal  adenopathy. 

In  general,  these  lesions  do  not  pass  the  balanitic  region,  for  which 
they  seem  to  have  a  specially  marked  predilection. 

Cylindroid  Syphiloma  of  the  Urethra. — Cylindroid  syphiloma  is  a 
gummatous  infiltration,  regular,  cylindric,  occurs  in  a  segment  of  the 
canal  and  may  lead  to  stricture.     It  occurs  under  two  forms: 
(a)  Sclerotic. 
(6)  Sclerogummatous. 
The  sclerotic  form  is  rare,  severe,  and  resistant  to  treatment. 


166  SYPHILIS  OF  THE  CKMTO-rRIXARY  OflG.-l.Y.s' 

The  sclerogummatous  form  is  benign  and  yields  rapidly  to  specific 
treatment;  the  guminata  disappear,  the  islands  alone  persisting.'    This 


FIG.  110. — Extensive  cununatous  destruction  of  the  jilans  penis  involving  the  urethra. 
Date  of  primary  infection  three  years.  Wassi-rmann  positive.  Xetrlected  treatment 
One  salvarsan  injection  made  in  May,  1911.  (Author's  <•-. 


FIG.  111. — Beginning  gumma  of  the  glans  penis  involving  the  urethra.    Previous  treat- 
ment none.     "Wastfermaun  positive.     (Author's  case.) 

condition  may  exist  at  the  same  time  as  other  gummatous  lesions  of  the 
canal,  from  which  it  seems  only  a  prolongation. 


SYPHILIS  <>i'  nil-:  I-RKTIIRA  167 


Complications    following    Tertiary    Urethral    Syphilis.  — 
Phagedenism,  according  to  Foumier,  is  the  most  serious  and 
coni])licatioii  that  can  occur.     He  says  that  one  should  be  imp: 
with  the  fact  that  genital  phagedenism  occurs  as  a  complication  in 
tertiary  syphilitic  lesions  more  frequently  than   in   simple  chancres. 
Here  phagcdena  of  the  urethra  may  destroy  not  only  the  meat  us, 
hut  also  may  extend  extensively  into  the  glans  portion  of  the  urethra. 
This  is  particularly  noticeable  inferiorly    where   gummata  are  most 
often  encountered.     From  this  extensive  destruction  hypospadias  of 
the  glans  portion  may  occur  to  a  greater  or  less  degree. 

fixtnla.  —  As  a  roult  of  this  extensive  destruction,  fistulas  are  very 
frequent.  They  may  be  in  the  following  locations:  fistulas  of  the 
balaiiopreputial  groove,  of  the  fo>si  navicularis,  or  of  the  body  of  the 
penis,  causing  destruction  of  the  penile  portion  of  the  urethra  to  a 
greater  or  less  extent. 

Albarran1  says:  "It  is  probable  that  certain  fistulas  are  veritable 
urinary  abscesses  with  secondary  infection,  the  microorganisms  gaining 
entrance  into  the  lesions  through  the  canal,  thus  acting  as  a  great  open 
portal  for  entrance  into  peri-urethral  tissue." 

Str/rf/irr.  Strictures  may  be  of  two  kinds,  false  or  pseudostrictures, 
and  true  strictiir* 

False  strictures  occur  during  the  formation  of  the  gumma  and,  once 
they  ulcerate  or  dissolve,  empty  their  contents  either  into  the  urethra 
or  externally,  and  the  strict  ure  disappears. 

True  or  cicatricial  strictures  occur  secondary  to  ulcerated  urethral 
gummata  or  following  phagedenic  ulceration,  or  as  a  sequel  to  cylin- 
droid  syphiloma. 

The  site  of  the  obstruction  depends  on  the  form  of  syphiloma  from 
which  it  is  derived.  It  is  most  frequently  found  at  the  meatus  or  in 
the  balanitic  region. 

The  diagnosis  of  this  form  of  stricture  must  be  made  on  the  particular 
history  of  the  patient.  Diagnosis  may  be  considered  under  the  follow- 
ing headings:  Wassermann  reaction,  microscopic  examination  of  the 
discharge,  and  a  careful  physical  examination. 

The  Wassermann  reaction  here,  as  in  other  forms  of  tertiary  syphilis, 
if  performed  by  a  careful  serologist,  should  be  positive  in  100  per  cent. 
The  urethral  discharge  is  very  characteristic.  The  diagnosis  is  made 
by  exclusion.  If  one  cannot  find  any  predominating  organism,  one 
should  be  suspicious  and  a  careful  search  continued  until  the  diagnosis 
is  positive. 

Erosive  and  gangrenous  balanitis  may  produce  destructive  symptoms 
at  times,  greatly  simulating  a  broken-down  gumma;  however,  micro- 
scopic examination  will  rapidly  settle  the  question. 

Epithelioma,  while  comparatively  rare,  must  be  thought  of.  Glan- 
dular enlargement,  however,  occurs  early.  Gummata  here,  as  elsewhere, 
grow  very  slowly  and  ulcerate  only  after  some  time.  They  are  only 
slightly  painful,  and,  as  a  rule,  are  attended  by  no  constitutional 
symptoms;  however,  both  gumma  and  neoplasm  have  the  common 


168  SYPHILIS  OF  THE  GENITO-URINARY  ORGANS 

characteristic  of  being  indurated.  The  cancerous  discharge  is  purulent, 
foul-smelling,  often  streaked  with  blood  and  the  pain  at  micturition  is 
severe.  If  the  urethra  is  explored  with  a  sound  or  bougie  there  is 
abundant  bleeding.  Often  the  sound  will  bring  away  particles  of  the 
tumor.  These  should  be  microscopically  examined  immediately. 
Xeoplasmic  induration  often  adheres  to  the  deeper  parts,  ulcerates  the 
skin  and  produces  fistula  surrounded  by  neoplasmic  offshoots. 

In  the  neoplasm  the  edges  of  the  ulceration  are  projective,  thick  and 
resistant;  the  surface  bleeds  easily,  with  a  characteristic  fetid  discharge. 

In.  syphilitic  gumma  there  is  no  adherence  to  subjacent  parts,  the 
base  is  unequal,  and  if  seen  early,  there  often  exists  a  yellowish  adherent 
scab  with  central  necrosis.  The  base  is  indurated  but  not  painful; 
secretion  is  not  marked.  The  Wassermann  reaction  is  always  negative 
in  epithelioma,  and  a  biopsy  will  rapidly  clear  up  the  diagnosis. 

Occasionally  urinary  abscess  may  be  mistaken  for  gumma.  Here 
the  history  either  of  traumatism  or  of  previous  stricture  should  be 
sufficient  to  make  the  picture  plain. 

Prognosis. — The  prognosis  of  primary  lesions,  whether  occurring  at 
the  meatus  or  endo-urethrally,  depends  on  a  prompt  diagnosis.  If 
treatment  is  beirun  early,  before  there  is  any  secondary  infection  and 
destruction,  these  lesions  cause  no  further  symptoms. 

However,  in  tertiary  syphiloma  the  prognosis  varies  according  to  the 
character  of  the  lesion.  In  simple,  uncomplicated  cases,  ulcerations 
scar  over  rapidly  and  gummata  dissolve.  But  if  there  is  great  destruc- 
tion of  tissue,  with  resulting  strictures,  treatment  may  be  prolonged 
and  unsatisfactory. 

Treatment. — In  chancre  of  the  meatus  and  endo-urethral  chancre  the 
treatment  is  the  same  as  described  under  primary  lesions  elsewhere. 
(See  Chapter  VIII,  p.  257,  under  Genital  Ulcers.) 

In  tertiary  lesions  of  the  urethra  the  treatment  is  the  same  as  that 
described  under  Tertiary  Lesions  of  the  Bladder. 

For  the  treatment  of  stricture  following  tertiary  lesions  of  the  meatus 
and  urethra  the  reader  is  referred  to  the  chapter  on  Strictures. 

SYPHILIS  OF  THE  PROSTATE. 

The  small  number  of  reports  in  the  literature  up  to  the  present  would 
seem  to  indicate  that  syphilis  of  the  prostate  is  extremely  rare.  Unlike 
the  bladder,  infections  in  the  prostate  only  manifest  themselves  in  the 
destructive  lesions  of  tertiary  syphilis.  In  this  condition  a  reliable 
Wassermann  report  is  the  best  aid  in  diagnosis. 

When  we  stop  to  consider  that  syphilitic  infection  can  occur  in  any 
part  of  the  human  organism,  it  is  only  natural  to  suppose  that  now  and 
again  it  would  involve  the  prostate.  Consequently,  if  we  hope  to 
recognize  this  condition  in  the  future,  it  will  be  necessary  carefully  to 
examine  all  cases  that  are  at  all  typical  for  prostatic  involvement. 

Among  the  cases  in  the  literature  heretofore  published  are  one  by 
M.  Drobney17  (1906),  another  by  F.R.  Wright19  (1912),  and  a  third  by 


SYPHILIS  OF  THE  BLADDER  169 

J.  O.  Rush18  (1913).  A  study  of  the  symptoms  in  these  cases  shows  that 
it  is  extremely  difficult  to  diagnose  this  infection  from  hypertrophy  of 
the  prostate,  as  they  both  occur  in  the  later  period  of  life  and  are 
attended  by  the  same  symptoms. 

SYPHILIS  OF  THE  BLADDER. 

By  syphilis  of  the  bladder  is  meant  only  those  diseases  which  involve 
the  bladder  mucous  membrane  itself.  All  those  affections  which  ex- 
tend from  the  surrounding  tissues  to  the  bladder,  whether  they  come 
from  syphilis  of  the  rectum  in  man  or  syphilis  of  the  uterus  and  vagina 
in  woman,  are  not  considered. 

Syphilitic  lesions  of  the  bladder  are  at  present  scarcely  known  and 
most  of  the  works  on  urology  and  syphilology  fail  to  make  mention  of 
the  subject. 

However,  observations  are  being  published  and  numerous  articles 
have  appeared  in  the  foreign  literature  describing  the  clinical  picture  in 
detail,  so  that  now  that  attention  has  been  brought  to  this  subject,  it 
is  highly  probable  that  numerous  cases  will  be  reported  in  the  future. 
The  history  of  this  affection  is  divided  into  three  distinct  periods: 

In  the  first  period  there  is  almost  complete  obscurity.  There  is 
cited  only  an  occasional  observation  of  autopsy  findings  in  syphilitics, 
dying  on  account  of  their  urinary  lesions,  ulcers,  perforations  and 
tumors,  which  were  discovered  on  opening  the  bladders.  This  extends 
down  to  the  year  1  Ml',  at  which  time  Tarnowsky41  reported  a  case  which 
is  described  later  on  in  this  chapter. 

In  the  second  period  are  related  some  clinical  observations,  the 
diagnosis  being  based  solely  on  the  result  of  treatment;  some  of  these 
observations  lack  accuracy. 

However,  a  sign  of  our  advance  in  understanding  this  condition  is 
the  fact  that  the  cases  published  during  the  second  period  were  all 
diagnosed  in  life  and  many  of  the  patients  recovered  under  specific 
treatment. 

In  the  third  period  diagnosis  was  made  by  the  cystoscope,  with  the 
addition,  many  times,  of  the  Wassermann  reaction. 

FIRST  PERIOD,  FROM  1767  TO  1872. 

During  this  period  9  cases  of  syphilis  of  the  urinary  bladder  were 
reported;  all  diagnoses  wrere  made  at  the  autopsy  table.  Of  these  9 
cases,  5  were  undoubtedly  gummata  and  4  were  secondary  lesions.  Fol- 
lowing is  a  brief  history  of  the  vesical  findings,  arranged  in  chronological 
order: 

Morgagni,33  in  1767,  at  the  autopsy  of  a  patient  who  presented  scars 
on  the  surface  of  the  penis  and  syphilitic  lesions  of  the  tongue  and 
epiglottis,  found  a  bladder  hollowred  out  by  ulcerations,  and  made  the 
diagnosis  of  syphilis  of  the  bladder.  This  observation  is  especially  of 
historic  interest,  but  on  authority  is  doubtful. 


170  SYPHILIS  OF  THE  GEN1 TO-URINARY  ORGANS 

Follin,24  in  1849,  found  in  a  woman  with  destructive  lesions  of  the 
bony  and  soft  palate  and  syphilitic  lesions  of  the  liver,  the  vesical 
mucous  coat  covered  with  twelve  small  tumors  about  the  size  of  lentils, 
making  slight  projections,  in  appearance  similar  to  vulvar  syphilitic 
papules. 

Ricord,10  in  1851,  reports  2  cases:  The  first  of  a  patient,  aged 
fifty-two  years,  without  special  antecedent  history,  who  for  two  months 
presented  a  urethral  discharge,  which  was  very  abundant,  persisting, 
and  a  little  painful.  At  the  end  of  fifteen  days  a  right  epididymitis 
appeared,  with  hydrocele;  a  month  afterward  the  discharge  was  still  very 
abundant  and  tinged  with  blood;  the  hydrocele  had  disappeared;  the 
epididymis  was  still  indurated.  Soon  a  left  epididymitis  with  hydro- 
cele manifested  itself.  Then,  in  spite  of  the  cure  of  the  lesions,  the 
discharge  persisted,  the  general  condition  was  aggravated,  and  death 
followed  four  months  after  the  beginning  of  the  infection.  At  the 
autopsy  the  membranous  and  prostatic  portions  of  the  urethra  were 
hollowed  out  by  deep  ulcers,  presenting  the  character  of  primary 
phagedena.  The  prostate  was  in  part  destroyed.  In  the  bladder  there 
existed  several  round  ulcerations,  with  borders  cut  into  peaks.  On  the 
left  side  the  seminal  vesicle,  the  vas  deferens,  and  even  the  testicle, 
showed  abscesses.  On  the  right  side  these  organs  were  normal. 

The  next  observation  dealt  with  a  young  man,  aged  eighteen  years, 
who  some  days  after  a  suspicious  coitus  had  contracted  a  chancre  of  the 
frenum  which  spread  from  place  to  place,  encroaching  on  the  meatus. 
A  little  later  an  abundant  discharge  appeared,  with  painful  urination. 
A  phimosis  formed,  the  constriction  of  which  was  removed  by  incision, 
but  the  edges  of  the  wound  ulcerated  and  the  ulceration  encroached  on 
the  glans  and  destroyed  it  almost  completely.  During  three  months 
the  discharge  persisted,  with  pain  and  incontinence  of  urine;  death 
followed  from  marasmus.  There  was  found  at  the  autopsy  an  ulcera- 
tion of  the  meatus  which  had  encroached  on  the  urethra,  and  a  second 
ulceration  much  elongated  on  the  surface  of  the  membranous  urethra 
and  in  the  prostatic  region.  The  vesical  neck  was  in  part  destroyed. 
The  vesical  cavity  was  filled  with  elevated  tumors,  reposing  on  an 
ulcerated  mucous  coat;  the  vesical  wall  was  hypertrophied. 

Virchow,44  in  1852,  at  autopsy  found  ulcerations  of  the  bladder  and 
urethra  in  a  woman,  aged  fifty-four  years,  who  for  fifteen  years  pre- 
sented periosteal  pains  and  syphilitic  ozena,  with  destruction  of  the 
nose  and  pharynx,  and  who,  during  the  first  month,  had  had  incon- 
tinence of  urine. 

Vidal,  of  Cassis,43  in  1853,  reported  the  case  of  a  patient,  aged  twenty- 
six  years,  who  had  had  a  chancre  three  years  previously,  and  who, 
having  presented  urinary  troubles,  urethral  discharge,  abdominal  pains, 
hematuria  after  micturition,  and  retention  of  urine,  succumbed  to  a 
generalized  peritonitis.  At  the  autopsy  there  existed  a  vesicoperitoneal 
fistula.  The  vesical  mucosa  presented  an  elevated  ulceration  with 
edges  cut  into  peaks,  rounded,  with  a  vascular  periphery  surrounded 
with  disseminated  plaques. 


SYPHILIS  OF  THE  BLADDER  171 

Tarnowsky,'1  in  1872,  reports  the  case  of  a  child,  aged  four  years, 
infected  by  its  foster-mother.  The  diagnosis  of  syphilis  not  having 
been  made  at  the  beginning,  and  the  child  having  been  treated  for 
eczema,  entered  the  hospital  in  a  deplorable  condition.  The  body  was 
covered  with  oozing  and  ecchymotic  papules.  The  mouth  and  throat 
were  covered  with  ulcerations  and  mucous  plaques  separated  by  dee]) 
fissures.  The  general  condition  was  not  favorable.  The  respiration  was 
difficult  and  anorexia  complete.  This  child  was  subjected  to  mercurial 
treatment,  baths  and  rubbings. 

Four  days  after  its  entrance  to  the  hospital  it  was  noticed  that  at 
each  micturition  the  child  was  extremely  agitated  and  experienced  pains 
in  the  genital  region.  On  examination  it  was  found  that  the  prepuce 
was  very  much  tumefied  and  inflamed,  that  the  urethra  was  indurated 
and  painful;  puncture  of  the  preputial  sac  allowed  a  purulent  greenish- 
yellow  liquid  to  escape.  The  patient  died  the  twelfth  day  after  his 
entrance  to  the  hospital.  At  the  autopsy  the  mucous  coat  of  the 
urethra  and,  in  part,  that  of  the  bladder  were  covered  with  superficial 
syphilitic  ulcerations.  The  pharynx  and  throat  were  sprinkled  with 
ulcerated  papules;  the  liver  was  syphilitic. 

Fenwick,23*  in  1879,  reported  the  case  of  a  twenty-three-year-old 
man  who  was  admitted  to  the  London  Hospital  for  a  stab  wound;  he 
died  of  the  injury.  Autopsy  showed,  beside  this  injury,  a  hard  chancre 
of  the  penis  and  adenitis  of  the  inguinal  and  lumbar  glands.  Elevated 
spots  were  seen  on  the  mucous  membrane  of  the  bladder,  which  looked 
like  condylomata. 

Neumann,*5  f  in  1899,  reported  a  case  of  gumma  of  the  bladder 
observed  by  him  in  a  forty-four-year-old  working  woman,  who  pre- 
sented in  the  bladder  numerous  round  whitish  nodules  the  size  of  a 
millet-seed,  some  of  them  isolated  and  some  in  groups. 

SECOND  PERIOD,  FROM  1872  TO  1900. 

Morris,34  in  1897,  reported  the  case  of  a  woman  who  had  bladder 
hemorrhage  for  months ;  she  had  lost  thirty  pounds  in  weight.  Morris 
made  a  cystoscopic  examination,  but  reports  nothing  definite;  specific 
treatment  caused  a  rapid  subsidence  of  symptoms. 

Griwzow,27  in  1899,  presented  observations  on  two  patients  attended 
by  urinary  troubles  of  a  doubtful  nature;  the  diagnosis  of  syphilitic 
cystitis  was  admitted,  because  of  the  action  of  the  mercurial  treatment, 
which  was  instituted  for  the  specific  lesions  in  other  organs. 

In  the  first  case,  a  woman,  aged  forty-two  years,  syphilitic  for  ten 
years,  presented  urinary  troubles,  pain,  and  intermittent  retention  of 
urine.  The  diagnosis  of  chronic  catarrh  of  the  bladder  had  been  made, 
but  the  mercurial  treatment  instituted  for  three  years  gave  no  results. 
At  this  time,  on  palpation,  a  compact,  rounded  tumor  could  be  felt 

*  These  authors'  cases,  while  appearing  in  publications  as  cited,  belong  to   the  first 
period,  1767  to  1872. 
t  Ibid. 


172  SYPHILIS  OF    THE   CEXITO-i'RIXARY  ORCA\S 

below  the  pubis,  also  palpable  by  the  vagina:  the  diagnosis  was  not 
definite.  At  the  same  time  the  particular  symptoms  pain  in  the  region 
of  the  liver,  with  palpable  hepatic  nodes,  diarrhea  and  vomiting,  caused 
a  diagnosis  of  gunima  of  the  liver  to  be  made,  and  in  several  months  the 
mercurial  treatment  caused  not  only  the  hepatic  symptoms  to  disappear 
but  the  vesical  condition  and  the  subpubic  tumor  as  well. 

The  second  observation  by  Griwzow  is  that  of  a  man,  aged  thirty 
years,  who  had  contracted  syphilis  six  years  before.  The  vesical  symp- 
toms and  the  pain  on  micturition,  which  he  had  for  two  years,  per- 
sisted in  spite  of  all  local  treatment.  A  perforation  of  the  bony  palate 
had  appeared.  Mercurial  treatment  was  given,  which  brought  about  a 
cure  not  only  of  the  soft  palate,  but  also  the  disappearance  of  the 
vesical  pains. 

Griwzow  had  in  these  2  cases  discovered  accidentally  the  specific 
nature  of  the  vesical  lesions. 

Chezelitzer,'2"2  in  1901,  presented  a  case  similar  to  that  of  Griwzow. 
He  treated  a  patient,  afflicted  with  vesical  pains  and  retention  of  urine 
for  a  long  time,  for  catarrhal  cystitis  and  prostatitis.  He  did  not  obtain 
any  result,  when,  one  day,  he  found  the  presence  of  syphilitic  lesions  of 
the  testicle  and  psoriasis  of  the  palms  of  the  hands.  Mercurial  treat- 
ment brought  about  the  cure  of  the  testicular  lesions  and  the  disappear- 
ance of  the  vesical  phenomena,  which,  indeed,  seemed  to  have  been  of 
syphilitic  nature. 

Margoulies,'0  in  1002,  reported  a  case  of  vesical  phenomena,  hema- 
turia,  incessant  desire  to  urinate,  diminution  of  vesical  capacity,  in  a 
man,  aged  fifty-five  years,  a  tabetic,  who  besides  had  a  nephritis 
(albumin  and  edema).  Margoulies  made  the  diagnosis  of  syphilitic 
cystitis,  and  mercurial  treatment  caused  the  vesical  symptoms  to 
disappear.  Unfortunately  cystoscopic  examination  had  not  been  made 
before  treatment,  and  when  made,  it  showed  only  a  bladder  rich  in 
trabecula?,  which  occurs  often  in  tabetics. 

Towbien,42  in  1904,  reported  a  case,  probably  a  gumma,  the  record 
of  which,  however,  is  incomplete. 

THIRD  PERIOD,  FROM  1900  TO  1916. 

The  rapid  progress  made,  coincident  with  the  development  of  the 
cystoscope,  in  the  diagnosis  of  vesical  lesions  is  particularly  noticeable 
during  this  period;  while  the  first  authentic  reports  of  Matzenauer31 
appeared  in  1900,  others  were  still  using  the  older  therapeutic  diag- 
nostic test  and  reporting  their  cases  (Chezelitzer,  Margoulies  and 
Towbien). 

It  is  interesting  to  note  how,  in  the  first  years  of  the  second  decade 
1^72  to  1900),  the  syphilitic  nature  of  the  bladder  infection  was  only 
occasionally  discovered,  and  how  later  physicians  came  to  consider  the 
possibility  of  bladder  syphilis  more  and  more,  and  how,  at  last,  Mat- 
zenauer,31 in  1900,  opened  the  modern  period  by  publishing  the  first  case 
of  syphilitic  ulcerations  of  the  bladder,  as  observed  by  means  of  the 


SYPHILIS  OF   THE  BLADDER  173 

cystoscope.     Since  then  the  serum  reaction  of  Wassermann  has  been 
added  as  strong  supporting  evidence  in  diagno- 

Syphilitic  lesions  of  the  bladder  may  be  of  two  kinds: 

1.  Secondary. 

2.  Tertiary/ 

Secondary  Bladder  Syphilis. — In  1S93  Neumann  called  attention 
to  the  fact  that  secondary  lesions  of  the  bladder  were  undoubtedly  not 
so  rare  as  was  previously  thought. 

Ernest  Frank,  in  1909,  presented  at  the  Congress  of  Urology  in  Berlin 
a  number  of  plates  of  cystoscopic  examinations  of  secondary  lesions  of 
the  bladder  before,  during,  and  after  treatment.  In  all  he  reported  5 
cases  that  had  never  been  published  before.  Unfortunately  I  have  not 
been  able  to  find  a  description  of  Frank  s  cases. 

Paul  Asch,-'J  in  1911,  reported  the  case  of  a  woman,  aged  twenty-eight 
years,  who  presented  all  the  signs  of  an  acute  cystitis  which  several 
doctors  had  diagnosed  as  gonorrhea.  At  the  time  of  examination  the 
patient  urinated  during  the  day  every  half-hour  and  at  night  every  ten 
minutes.  There  was  persistent  and  severe  strangury,  accompanied  by 
terminal  hematuria.  Tuberculosis  having  been  excluded  by  inoculation 
and  microscopic  tests,  a  cystoscopic  examination  was  made  which  showed 
the  following  picture :  The  whole  of  the  bladder  mucous  membrane  was 
very  much  swollen  and  red,  and  scattered  over  it  at  irregular  intervals 
were  hard,  superficial,  round,  and  oval  defects  in  the  mucous  membrane, 
with  small  undermined  edges  and  whitish  ba>e.->.  They  looked  like 
syphilitic  patches  such  as  are  found  in  the  mouth  in  the  secondary 
stages  of  syphilis.  Examination  of  the  inguinal  glands  showed  them  to 
be  large,  hard,  and  painless  on  both  sides.  The  patient  now  admitted 
that  one  year  and  three  months  before,  she  had  had  a  small  ulcer  on  the 
left  labium  that  had  recovered  under  local  treatment,  and  had  not  been 
followed  by  any  other  symptoms. 

Mercury  inunctions  were  ordered.  During  the  first  week  of  the 
treatment  the  symptoms  seemed  rather  to  increase,  which  was  probably 
the  result  of  irritation  from  the  cystoscopic  examination,  but  may  also 
have  been  a  reaction  from  the  treatment  itself.  At  the  end  of  the 
second  week  the  symptoms  began  to  improve.  The  urine  cleared  up, 
the  general  condition  improved,  and  in  the  fourth  week  the  picture  was 
very  different.  The  patient  had  increased  fourteen  pounds  in  weight ; 
she  could  retain  her  urine  two  to  three  hours  in  the  day,  and  only  had 
to  get  up  once  during  the  night.  The  urine  was  almost  clear,  contain- 
ing only  a  few  red  blood  cells  and  leukocytes.  The  cystoscope,  at  the 
end  of  the  fourth  week,  showed  the  mucous  membrane  only  a  little 
reddened,  with  small  white  flecks  of  mucus.  In  the  sixth  week  the 
bladder  was  completely  normal,  so  that  treatment  could  be  given  up. 
A  year  later  the  patient  came  for  examination,  and  bladder  and  urine 
were  both  normal. 

This  case  is  undoubtedly  one  of  those  rare  ones,  not  previously 
reported  in  the  literature,  of  secondary  syphilitic  disease  of  the  bladder 
corresponding  to  the  patches  in  the  mouth  and  sexual  organs. 


174  SYl'IlILIS  OF  THE  GENITO-URINARY  ORGANS 

Pereschiwkin,37  in  1911,  published  o  cases  of  "papulous  exanthema 

of  tlie  vesical  mucous  coat;"  all  these  patients  showed  lesions  on 
the  skin  and  mucous  surfaces,  together  with  vesical  symptoms. 

In  the  first  patient  the  cystoscopic  examination  showed  a  normal 
vesical  mucous  coat  with  the  exception  of  the  base  of  the  bladder,  which 
was  edematous  and  hyperemic.  On  the  periphery  of  the  left  ureter  one 
saw  several  ulcerations  with  edges  elevated  and  infiltrated.  The  base 
was  very  red,  the  ureteral  orifices  were  normal. 

In  the  second  there  existed  in  the  region  of  the  summit  of  the 
bladder  seven  small  ulcerations  with  infiltrated  edges. 

In  the  third  patient  the  vessels  of  the  mucous  coat  were  strongly 
injected  and  the  ve-ical  sphincter  was  edematous;  on  all  the  mucous 
coat,  especially  at  the  base  of  the  bladder,  there  existed  small  arc-as  of 
ulcerations  of  variable  forms  and  dimensions,  some  with  edges  infil- 
trated, others  with  flat  edges.  The  ureteral  orifices  were  a  little  edema- 
tons.  Mercurial  treatment  brought  about  a  rapid  disappearance  of  the 
symptoms.  (Plate  I,  Figs.  1  and  \ 

Michailoff,32  in  1912,  published  a  case  of  a  woman,  aged  thirty-nine 
years,  who  complained  of  bladder  pain  radiating  into  the  hips;  hema- 
turia  was  periodic  over  a  period  of  five  years.  Gradually  the  hematuria 
increased  in  amount  and  frequency.  There  were  no  pains  during  the 
hematuria,  and  the  temperature  was  normal.  The  details  of  the  cysto- 
scopic picture  were  as  follows:  On  the  lateral  and  superior  wall  of  the 
bladder,  characteristic  rows  of  vesicles  covered  by  yellowish-gray 
crusts  were  visible;  each  vesicle  was  surrounded  with  small  areas 
of  the  color  of  red  raspberries  which  sharply  contrasted  with  the 
normal  coloring  of  the  neighboring  mucous  coat.  Here  and  there 
injected  vessels  were  seen,  the  rows  of  circles,  which  were  surrounded 
by  little  "coronas,"  looking  like  the  papules  which  we  are  accus- 
tomed to  see  on  the  epidermis.  Later  on,  at  a  second  cystoscopic  ex- 
amination, catheterization  showed  that  the  hemorrhage  came  from  the 
left  kidney.  In  secondary  affections  of  the  bladder  and  upper  urinary 
tract  hemorrhage  has  never  been  observed.  It  is  possible  that  the 
hemorrhage  came  from  the  renal  papilla  or  from  minute  bloodvessels. 
It  resembled  that  form  of  hemorrhage  that  is  spoken  of  as  "essential 
hematuria."  The  diagnosis  in  this  case  was  based  entirely  on  the 
cystoscopic  examination,  afterward  confirmed  by  the  Wassermann 
reaction,  with  prompt  disappearance  of  local  and  general  symptoms 
as  a  result  of  specific  therapeusis. 

Mucharinsky,35  in  1912,  reported  the  case  of  a  patient  who  a  year 
before  had  had  a  hard  chancre;  later  roseola  and  treatment.  There  were 
no  objective  signs  of  syphilis;  glands  not  palpable;  no  urethral  discharge; 
there  was  painful  urination  by  day  and  night ;  a  catheter  had  been  used 
for  two  weeks.  Cystoscopic  examination  showed  diffuse  bluish-red 
hyperemia  of  the  neck  of  the  bladder  and  trigone;  middle  lobe  of  the 
prostate  protruded  considerably  into  the  bladder;  bladder  tense;  on 
the  mucous  membrane  flakes  of  mucus;  on  the  fundus  of  the  bladder 
an  ulcer  the  size  of  a  copper  coin,  with  jagged,  strongly  hyperemic 


PLATE   I 


FIG    1 


FIG.   2 


Secondary  Syphilis  of  the  Bladder  Mucous  Membrane  as 
described  by  Pereschiwkin. 

Fiy.  1  shows  the  vessels  of  the  mucous  coat  strongly  injected  with  some 
edema  around  the  internal  sphincter.  All  over  the  mucous  membrane, 
especially  on  the  base,  are  ulcerations  of  various  forms  and  dimensions, 
some  flat,  others  with  infiltrated  edges. 

Fig.  2  shows  complete  disappearance  after  mercurial  treatment. 


SYPHILIS  OF  THE  BLADDER  175 

edges;  on  the  base  of  the  ulcer  a  blood  clot.  Complete  healing  took 
place  under  specific  treatment.  This  case  belongs  to  the  secondary 
erythemata  of  the  bladder  with  ulcer  formation. 

The  author  has  had  the  opportunity  to  examine  cystoscopically  one 
case  of  secondary  syphilis  in  a  young  man  with  a  diffuse  macular  erup- 
tion, without  any  bladder  symptoms.  The  mucous  membrane  was 
diffusely  hyperemic;  the  vessels  were  injected,  with  numerous  islands 
of  mucus  adherent  throughout.  Urine  from  both  kidneys  showed  a 
large  number  of  leukocytes,  but  no  organisms. 

Tertiary  Bladder  Syphilis.—  Matzenauer,31  in  1900,  heretofore  men- 
tioned as  the  first  to  publish  a  case  of  syphilitic  lesion  of  the  bladder 
ascertained  by  the  cystoscope,  describes  a  case  of  a  girl,  aged  twenty- 
two,  a  syphilitic  for  four  years,  whose  vesical  neck  was  covered  with 
papilloma-like  projections  resembling  villosities;  the  rest  of  the  mucous 
coat  of  the  bladder  was  normal.  On  the  superior  wall  of  the  urethra  a 
superficial  ulceration  existed,  with  edges  cut  into  peaks,  reaching  the 
internal  orifice.  Matzenauer  made  a  diagnosis  of  gummata  of  the 
urethra  and  bladder. 

MacGowan,*9  in  1901,  reported  a  case  of  a  patient,  syphilitic  for  ten 
years,  who  presented  urinary  troubles  and,  in  particular,  vesical  pains, 
with  frequent  desire  to  urinate  and  with  retention  of  urine.  The  local 
treatment  brought  no  amelioration;  he  made  a  cystoscopic  examina- 
tion. He  found  on  the  posterior  part  of  the  vesical  mucous  coat 
numerous  papilloma-like  projections  and  behind  the  right  ureteral 
orifice  several  concentric  ulcerations,  with  hard  edges,  infiltrated,  the 
syphilitic  nature  of  which  could  not  be  doubted. 

While  syphilis  of  the  bladder  is  not  so  frequent  in  this  country  as  it  is 
abroad,  and  as  a  consequence  not  so  easily  diagnosed,  MacGowan 
deserves  credit  for  his  pioneer  report  of  a  case  diagnosed  by  means  of 
the  cystoscope. 

Graff,26  in  1906,  mentions  a  case  in  a  fifty-six-year-old  man,  who, 
thirty-five  years  before,  had  had  a  gonorrhea  and  small  ulcers  on  the 
penis,  and  who  was  admitted  to  the  hospital  because  of  repeated 
hemorrhages  from  the  bladder.  For  some  months  there  had  been  pain 
in  the  perineum  and  limbs,  extending  sometimes  to  the  glans  penis. 
Urination  was  difficult.  Both  testicles  showed  a  moderate  doughy 
swelling,  but  no  pain.  Catheterization  was  rendered  difficult  by  a 
contracted  external  urethral  orifice.  Cystoscopy  could  not  be  per- 
formed on  account  of  the  bladder  hemorrhage.  The  urine  was 
bloody  and  purulent.  No  tubercle  or  other  bacilli  could  be  demon- 
strated in  the  urine.  The  general  condition  improved  under  irrigation 
of  the  bladder  with  weak  silver  nitrate  solution  and  the  hemorrhage 
and  other  symptoms  decreased,  so  that  the  patient  thought  of  leav- 
ing the  hospital;  cystoscopy  was  now  possible  and  it  showed,  at  the 
summit  of  the  bladder,  a  tumor-like  newr  growth  with  a  defect  in  the 
centre  and  papillary  proliferation  of  the  edges,  so  that  papilloma  was 
suggested,  or  several  small  papillomata. 

Suprapubic  cystotomy  was  performed.   At  the  summit  of  the  bladder 


176  SYPHILIS  OF   THE  GBNITO-UBINABY  OflGV 

there  was  an  ulcer  extending  into  the  muscular  layer,  from  the  K 
which  white  particles  could  easily  be  removed.  The  ulcer  was  cauter- 
ized, the  bladder  closet!  by  suture,  with  drainage  through  a  catheter. 
The  wound  healed  uneventfully.  After  opening  the  bladder,  the  nature 
of  the  tumor  could  be  better  recognized.  In  connection  with  the  swell- 
ing of  the  testicle,  it  suggested  syphilis.  Syphilis  had  been  thought  of 
before,  but  the  history  alone  did  not  give  sufficient  grounds  for  it.  The 
diagnosis  of  gumma  of  the  bladder  and  bilateral  gummatous  orchitis 
onfirmed  by  the  results  of  the  antisyphilitic  treatment,  which  was 
now  begun.  Six  weeks  after  the  operation  the  patient  was  discharged, 
completely  cured. 

The  excised  piece  consisted  chiefly  of  necrotic  cell  masses  and  bladder 
epithelium,  which  did  not  show  any  tumor-like  degeneration. 

Le  Fur,-s  in  19(>2.  reported  the  case  of  a  patient  who  had  never  had 
gonorrhea,  but  eight  years  before  had  had  syphilis,  which  was  treated 
very  irregularly.  Two  years  before  hematuria  had  appeared,  which 
lasted  throughout  the  act  of  urination.  This  occurred  several  times  at 
irregular  intervals,  but  without  pain  and  without  any  other  bladder 
symptoms.  A  few  months  before  a  more  severe  hematuria  than  usual 
had  appeared,  which  caused  urinary  retention  by  the  formation  of  clots 
in  the  bladder.  The  aspiration  of  these  clots  stopped  the  hemorrhage, 
but  it  must  have  been  profuse,  for  the  patient's  mucous  membrane  was 
very  pale.  The  urine  was  turbid,  contained  numerous  red  blood  cells 
and  leukocytes,  but  no  bacteria.  The  capacity  of  the  bladder  was  good. 
The  prostate  was  very  hard  and  irregular,  and  in  the  right  lobe  a 
large,  hard  nodule  could  be  felt.  The  author  suspected,  therefore, 
that  the  hemorrhage  was  caused  by  chronic  prostatitis  and  began 
treatment  for  that.  As  this  treatment  had  no  effect  he  made  a  cysto- 
scopic  examination. 

lie  found  a  group  of  three  ulcers  in  the  region  of  the  trigone,  one  of 
which  was  of  some  depth,  had  fissured  edges  and  a  gray  base.  From 
these  findings  he  suspected  an  infection  of  the  bladder  from  the  dis- 
ea-ed  prostate  and  irrigated  the  bladder  with  a  solution  of  silver  nitrate. 
Since  the  urine  remained  turbid  even  after  this  treatment,  and  as 
syphilitic  patches  developed  in  the  pharynx,  the  author  concluded  that 
syphilis  was  the  cause  of  the  bladder  disease,  and  antisyphilitic  treat- 
ment brought  about  complete  recovery  in  a  short  time.  The  urine 
became  clear  and  free  of  blood,  the  prostate  soft  and  the  nodules  disap- 
peared, (.'ystoscopy  showed  white  scars  in  place  of  the  ulcers  in  the 
bladder. 

Margoulies,  in  1912,  reported  the  case  of  a  woman,  aged  forty-one 
years,  who  presented  intermittent  hematuria,  with  pains  in  the  left 
hypochondriac  region,  radiating  toward  the  bladder,  with  frequent 
desire  to  urinate:  cystoscopic  examination  showed  a  little  behind  and  to 
the  left  of  the  left  ureteral  orifice  a  neoplasm  formed  of  three  tumors, 
each  the  size  of  a  bean;  these  three  excrescences  were  very  close  to  each 
other  and  the  sides  turned  toward  the  summit  of  the  bladder  were 
covered  with  a  visible  membrane;  all  around  the  mucous  coat  was 


SYPHILIS  OF   THE  BLADDER  177 

hyperemic.     Having  made  the  diagnosis  of  cancer  of  the  bladder, 
Margoulies,  in  proposing  ablation,  noticed  that  the  patient  bore  on  her 
whitish  scars  and  had  in  her  previous  history  a  miscarriage.     He 
had  her  take  potassium  iodide.     To  his  great  surprise  it  produced  a 
rapid  amelioration,  and  a  month  later  the  vesical  tumors  had  disap- 
peared, leaving  on  the  mucous  coat  little  insignificant  scars. 
Yon  Engelmann,45  in  1911,  reported  the  following  3  cases: 

His  first  case  was  in  a  sixty-year-old  woman  who  had  had  bladder 
hemorrhages  for  six  months,  without  any  other  bladder  symptoms. 
( Ystoscopic  examination  showed,  above  the  right  ureter,  a  tumor 
about  3  cm.  long,  with  ulcerated  surface  covered  with  a  purulent  mem- 
brane, and,  in  places,  encrustation.  The  author  thought  the  tumor 
was  a  carcinoma  and  proposed  an  operation;  then  he  found  that  the 
patient  had  acquired  syphilis  twenty  years  before  and  ordered  mercury 
treatment.  The  ulcerations  healed  rapidly  and  the  entire  tumor  disap- 
peared in  a  few  weeks. 

The  second  case  was  that  of  a  man,  aged  forty-six  years,  who  had 
suffered  from  hematuria  at  times  during  the  preceding  three  months. 
He  had  had  syphilis  fifteen  years  before  and  a  mercury  and  potassium 
iodide  treatment.  A  year  before  paralysis  of  the  left  leg  had  developed, 
which  disappeared  after  mercurial  treatment.  The  urine  was  turbid, 
and  at  the  end  of  urination  there  was  slight  pain.  Cystoscopic  ex- 
amination showed,  beneath  the  opening  of  the  right  ureter,  a  round, 
prominent  tumor  about  the  size  of  a  hazel-nut,  with  surface  partly 
ulcerated  and  covered  with  purulent  membrane  and  with  papillary 
characteristics  in  places.  At  that  time  there  were  no  other  syphilitic 
symptoms.  The  author  made  a  diagnosis  of  gumma  of  the  bladder 
and  advised  antisyphilitic  treatment.  Cystoscopic  examination,  after 
thirty  mercurial  inunctions,  showed  that  the  tumor  had  disappeared 
and  there  was  a  red  spot  in  place  of  it.  Xo  local  treatment  had  been 
given. 

The  third  case  was  that  of  a  woman,  aged  forty-seven  years,  who  had 
had  paralysis  of  both  legs  for  a  year.  She  had  had  painful  urination 
for  a  month.  There  was  a  history  of  three  abortions  twenty  years 
before.  Examination  showed  syphilitic  myelitis,  ulcerated  papules  of 
the  labia  majora,  swelling  of  the  inguinal  glands,  paresis  of  the  detrusor 
vesicae  and  also  of  the  extremities.  The  urine  was  turbid,  contained 
much  pus,  streptococci,  and  Gram-positive  diplococci;  tubercle  bacilli 
could  not  be  demonstrated.  Cystoscopy  showed  reddening  of  the 
bladder,  and  in  the  region  of  the  opening  of  the  left  ureter,  completely 
surrounding  it,  a  large  ulcer  covered  with  encrustations  which  pro- 
jected into  the  bladder.  Similar  encrusted  ulcers  were  found  in  the 
summit,  and  on  the  lateral  and  anterior  wall.  They  were  all  of  dif- 
ferent sizes,  up  to  5  cm.  The  encrustations  could  hardly  be  separated 
with  the  catheter;  when  separated,  hemorrhages  occurred.  The  sur- 
faces of  the  ulcers  were  papillary  in  appearance. 

Antisyphilitic  treatment,  combined  with  bladder  irrigations,  brought 
slow  but  progressive  improvement  in  all  the  symptoms.  The  paresis 

M  U       1—12 


17*  >F   THE  (if-:  MT<>-riU\ARY  ORGANS 

disappeared  and  cystoscopic  examinations,  repeated  at  regular  inter- 
vals, showed  progressive  improvement  of  the  cystitis  as  well  as  of  the 
uleers.  The  encrustations  gradually  came  off  and  were  discharged 
with  the  irrigations.  After  two  months  the  bladder  mucous  membrane 
was  normal.  In  some  places,  where  the  larger  ulcers  had  been,  there 
were  white  scars  on  the  mucous  membrane,  a  sign  that  they  had  not 
been  superficial  erosions,  but  deep  ulcers. 

i  says  that  we  will  probably  not  err  in  saying  that  the  ulcers  and 
encrustations  in  von  Engelmann's  third  case  were  only  indirectly  caused 
by  syphilis. 

:i.-1  in  1911,  reported  the  case  of  a  man,  aged  forty-five  years. 
who  had  suffered  for  three  months  from  bloody  urine;  no  other  symp- 
toms. General  condition  good.  Previous  treatment  had  not  affected 
the  disease.  Suddenly  a  hemorrhage  appeared  without  explainable 
cause.  Its  duration  from  the  beginning  to  the  end  of  urination,  and 
the  failure  of  previous  methods  of  treatment,  caused  Aschto  suspect  a 
tumor.  The  lack  of  other  symptoms  indicated  that  it  was  probably 
in  the  summit  of  the  bladder.  Cystoscopic  examination  showed 
papilla?  the  size  of  a  hazel-nut  about  0.5  cm.  externally  from  the  open- 
ing of  the  left  ureter,  and  directly  above,  partially  covered  by  the 
papillu\  an  ulcer  about  1  cm.  in  diameter  with  hard,  infiltrated  edges 
and  grayish-yellow  purulent  masses  covering  its  base.  This  ulcer 
aroused  a  suspicion  of  syphilis.  The  patient  admitted  that  he  had  had 
syphilis  about  twenty  years  previously,  and  that  he  had  hardly  been 
treated  at  all.  Bacterial  examination  of  the  urine  showed  that  there 
were  no  gonocooci  or  tubercle  bacilli. 

This  shows  that  syphilis  may  produce  papillomata  which  are  very 
similar  to  the  ordinary  papillomata  in  appearance. 

i  reports  a  second  case  of  a  man,  aged  thirty-five  years,  who,  for 
three  months,  had  had  severe  bladder  hemorrhages  and,  for  six  weeks, 
painful  desire  to  urinate.  The  urine  hail  recently  become  turbid  and 
contained  many  leukocytes  and  a  considerable  number  of  red  cells. 
There  was  an  ulcer  on  the  right  thigh  which  had  persisted  for  five 
months,  and  which  had  had  all  the  characteristics  of  a  gummatous  ulcer. 
Twenty  years  before  the  patient  had  had  a  hard  chancre  which  was 
only  superficially  treated,  but  no  other  symptoms  until  the  gummatous 
ulcer  developed.  Cystoscopic  examination  showed  a  large  gummatous 
ulcer  in  the  fundus.  It  was  2  or  3  cm.  in  diameter,  had  edges  very 
much  infiltrated,  and  projected  1  cm.  into  the  bladder.  The  base  of 
the  ulcer  was  yellowish  and  projected  above  the  mucous  membrane. 
There  was  no  doubt  of  the  diagnosis.  The  patient  received  an  intra- 
venous injection  of  sal  varsan,  0.5  gm. ;  the  result  was  excellent.  After 
four  days  the  gummata  of  the  thigh  and  the  bladder  had  completely 
disappeared.  ( 'ystoscopy  showed  a  normal  bladder. 

Picot,w  in  1912,  gives  the  details  of  one  case  of  vesical  syphilis  in  a 
patient,  aged  fifty-three  years,  who  denied  all  venereal  disease.  The 
patient  began  to  have  urinary  symptoms  eight  years  previously, 
apparently  without  cause;  at  the  end  of  two  years  he  was  operated  on 


."////./.<  Of-'   THE  BLADDER 

for  vesical  calculi.  One  clay,  a  year  afterward  increased  and 

brown  masses  appeared  in  the  urine;  later  most  of  the  urine  passed 
through  the  rectum.  1  the  left  ureteral  orifice 

round,  large,  and  gaping.  A  little  below  this  orifice  the  vesical  wall 
•  rotif.  I>argeprr>:-  were  visible,  intersected 

by  longitudinal  furrows  on  which  finer  -anched.  This  aspect 

recalls  that  of  a  parquetted  floor.  The  right  ureteral  orifice  was 
elongated  tra  .  The  bladder  mucous  coat  which  surrounded 

it  wa>  pal<-.  This  pallor  «  1  with  the  deep  coloration  of  the 

region  of  the  trigone.  Abr>ve  and  below  the  ureteral  orifice,  almost 
touching  it,  were  found  small  irregular  plaques  of  a  clearer  red,  sur- 
rounded by  a  sort  of  halo.  The  edges  were  irregular,  and  a  little 
I>olycyelic.  It  was  above  this  region  that  the  more  characteristic  ele- 
ments w<-r«-  di-<  ..vered.  At  thi>  point  the  vesical  wall  was  covered 
by  numerous  ulcerations  of  some  depth;  they  were  very  variable 
a-  to  dimensions  and  some  were  confluent.  Their  border  was 
lar  and  polycyclic,  the  ba^e  was  red  at  the  periphery,  paler  at 
••ntre.  These  elements  had  the  aspect  of  ulcerous  syphilides. 
The  po-terior  part  of  the  bladder  on  the  right  side  presented  the  same 
parquettcd  n>pe<-t  a-  that  which  has  been  described  of  the  left  ureter. 
In  the  midst  of  the  projections,  in  a  cavity,  a  fistula  was  found.  It  was 
an  irregular  orifice,  the  borders  of  which  were  cut  into  peaks.  It 
appeared  to  be  about  0.25  cm.  in  diameter.  Below  this  orifice,  floating 
in  the  liquid  were  two  blackish  bodies  (debris  of  fecal  matter). 

The  .summit  of  the  bladder  was  occupied  by  small  tuberculous 
•me  of  which  were  massed  together,  others  isolated,  slightly 
ulcerated  at  their  apices.  At  the  left  posterior  part  of  the  bladder, 
at  a  point  where  the  preceding  formations  were  found  there  was  a 
large  vari«  •  1,  emerging  into  the  bladder  like  a  temporal  arterio- 

>clern>ir..  Papulo-ulcerative  element  <  in  a  fistula,  the  edges  of  which 
are  cut  into  peak>.  suggest  syphilis.  The  patient  denied  having 
contracted  a  chancre,  but  the  Wassermann  reaction  was  found  to  be 
positive. 

R.  Picker.**  in  1913,  reported  the  case  of  a  solitary  gumma  of  the 
bladder  in  which  he  maintains  that  the  diagnosis  is  the  earliest  on  record 
for  this  class  of  ca-e-.  The  Wassermann  examination  was  negative. 
This,  however,  was  before  the  ulcer  had  broken  down.  There  was  no 
hemorrhage.  The  clear  urine  and  the  normal  adnexa  pointed  to  the 
localization  of  the  condition  in  the  bladder.  Complete  healing  took 
place  under  specific  treatment. 

(  ysto-copy  showed  the  vault  thoroughly  smooth  and  pale  yellow. 
Both  ureteral  folds  were  clearly  defined  throughout  their  whole  course. 
The  openings  of  the  ureters  appeared  at  the  end  of  the  ureterai  folds 
in  the  form  of  small,  papilhe-like  protuberances.  The  stream  of  urine 
from  both  sides  was  strong.  At  the  posterior  end  of  the  trigone,  the 
mucous  membrane  appeared  entirely  normal  and  smooth,  while  on  the 
infernal  side  of  the  right  ureteral  fold,  there  was  a  cystoscopic  picture 
of  a  prominence  about  the  size  of  a  quarter  of  a  dollar,  which  was  sur- 


180  SYPHILIS  OF   THE  GEN  I  TO-URINARY  ORGANS 

rounded  by  a  narrow  but  livid  red  border  which  gradually  passed  over 
into  the  normal  neighboring  mucous  membrane.  The  surface  of  the 
prominence  itself  appeared  yellowish,  tinged  with  red,  and  was  demar- 
cated from  the  livid  border  by  a  margin  formed  of  five  segments  coming 
together  at  an  obtuse  angle.  In  the  middle  of  this  formation  there 
was  a  depression  covered  with  a  thick  whitish  eschar  about  the  size 
of  a  five-cent  piece.  The  entire  formation  was  like  a  pansy  in  shape. 
Healing  took  place  under  specific  treatment. 

Gayet  and  Favre,25  in  1914,  reported  under  this  heading  3  cases. 
The  first  had  the  following  history : 

A  tabetic,  aged  sixty-six  years,  whose  urinary  symptoms  began 
fifteen  months  previously  with  a  pollakiuria,  most  frequent  at  night, 
gradually  growing  worse;  repeated  attempts  at  cystoscopy  were  not 
successful.  Later,  however,  the  following  picture  was  visible.  On 
December  9,  1913,  the  patient  continued  to  bleed;  ureteral  orifices 
clearly  visible.  Medium  prostatic  projection;  at  its  site  an  ulcer  with 
irregular  contour.  Two  other  ulcerations  were  found  on  the  upper 
side  of  the  left  ureteral  orifice,  in  the  form  of  papules,  covered  over 
with  a  greenish-white  exudation.  This  suggested  the  specific  nature  of 
the  lesion  and  the  patient  who  had  been  until  then  treated  by  washings 
only,  was  subjected  to  weekly  injections  of  calomel  and  potassium 
iodide.  The  \Yassermann  was  positive  at  this  time.  After  the  first 
week  of  treatment,  the  hematuria  ceased,  not  to  reappear,  but 
incontinence  persisted.  January  17,  1914,  after  six  months  of  treat- 
ment, cystoscopy  showed  a  little  vesicular  vascularization,  especially 
in  the  prostatic  region,  but  there  the  preexisting  ulceration  was  no 
longer  to  be  seen.  The  neighboring  ulcerations  of  the  left  ureter 
were  in  process  of  cicatrization;  there  was  a  sort  of  gray  edematous 
covering. 

They  conclude  as  follows:  "An  old  syphilitic,  tabetic,  attended  with 
chronic  retention,  with  ordinary  cystitis,  had  suddenly  a  hemorrhage; 
the  hemorrhage  repeated  itself  in  capricious  manner,  without  provoca- 
tion, recalling  the  hemorrhage  of  neoplasms.  It  persisted  until  the 
day  when  mercurial  treatment  was  begun  and  then  disappeared 
rapidly.  The  cystoscopy,  which  at  this  time  was  not  clear,  gave  the 
impression  that  there  were  ulcerations  of  specific  nature.  In  ten  weeks, 
under  the  influence  of  mercury,  iodides,  and  finally  neosalvarsan,  these 
ulcerations  completely  scarred  over. 

"  The  only  objection  which  could  be  made  to  the  diagnosis  of  vesical 
syphilis  is  that  it  might  have  been  a  question  of  ulcerous  cystitis, 
occurring  by  ordinary  infection  in  a  tabetic  bladder  during  retention, 
or  the  result  of  trophic  lesions  of  medullary  origin." 

Gayet  and  Favre's  second  case  is  that  of  a  patient,  aged  fifty  years, 
who  denied  venereal  history.  Seven  years  previously  there  was  per- 
foration at  the  junction  of  the  hard  and  soft  palate.  The  patient 
suddenly  had  very  intense  hematuria,  accompanied  by  pains  at 
micturition  and  with  pollakiuria;  these  functional  symptoms  dimin- 
ished soon;  the  hematuria  was  pronounced  from  the  moment  of 


,sT/'///L/S  OF   THE  BLADDKI!  1M 

entrance  to  the  hospital  and  did  not  quiet  down  under  the  influence 
of  rest.  The  first  cystoscopy  was  not  satisfactory  on  account  of  the 
hemorrhage.  Salvarsan  treatment  was  instituted.  Later  cystoscopic 
examination  showed  the  following  (five  days  after  the  first  injection  and 
one  month  after  the  patient's  entrance):  The  base  of  the  bladder  was 
red,  the  remainder  of  the  mucous  coat  less  red,  but  there  existed 
numerous  papfllomata  around  the  neck  and  the  general  aspect  of  a 
cerebral  convolution  still  persisted,  but  with  ridges  and  folds  less  pro- 
nounced. Later,  the  patient,  who  had  quit  the  service,  returned  for  a 
cy^toseopy.  She  had  not  had  the  least  trouble  or  the  least  hematuria 
since  the  last  examination.  Her  bladder  was  entirely  normal,  except 
at  the  boundary  of  the  neck,  where  several  ridges  still  persisted,  with 
the  mucous  coat  a  little  irritated. 

The  third  case  was  that  of  a  woman,  aged  thirty-five  years.  Eleven 
years  previously  she  had  had  a  chancre  on  the  lip;  fifteen  days  before 
her  admittance  to  the  hospital  she  suddenly,  without  premonitory 
symptoms,  began  to  urinate  blood.  The  first  hematuria  was  of  terminal 
character  and  accompanied  by  pain  with  the  last  drops.  There  was 
pollakiuria,  especially  on  standing.  Cystoscopy  showed  the  bladder 
white  throughout;  the  ureteral  orifices  presented  nothing  abnormal. 
The  trigone  was,  on  the  other  hand,  somber  red,  with  a  median  pro- 
jection recalling  a  prostatic  lobe.  The  periphery  of  the  neck  was  red, 
the  folds  much  affected.  No  ulcerations  were  seen.  Vaginal  examina- 
tion was  negative.  Simple  rubbings  brought  about  complete  cure. 

Pathology. — The  pathology  of  vesical  syphilitic  lesions  is  the  same 
as  that  found  in  syphiloma  in  other  parts  of  the  body. 

Symptoms. — SECONDARY  SYPHILIS. — Age. — It .  generally  occurs  in 
early  adult  life. 

During"  the  period  of  secondary  eruption,  if  the  infection  is  severe, 
there  frequently  occurs  a  diffuse  syphilitic  cystitis. 

If  one  stops  to  consider  that  during  the  period  of  secondary  invasion 
the  spirochetes  localize  in  every  organ  of  the  human  body,  it  is  not  sur- 
prising that  at  times  there  should  be  vesical  lesions  during  this  period; 
however,  in  the  majority  of  cases,  they  are  overshadowed  by  the  general 
infection  and  rapidly  lose  their  identity  once  specific  treatment  is 
instituted. 

In  the  more  severe  infections  there  are  all  the  symptoms  of  acute 
and  chronic  inflammation  of  the  bladder,  i.  e.,  pyuria,  pollakiuria, 
pain,  and  tenesmus.  It  must  not  be  forgotten  that  secondary  lesions, 
no  matter  where  located,  are  not  destructive,  and  as  a  consequence  the 
accompanying  symptomatology  may  be  insignificant,  compared  with 
that  of  gumma. 

During  this  period  secondary  symptoms,  such  as  mucous  plaques, 
condylomata  and  secondary  skin  eruptions  are  common. 

Cystoscopic  Examination. — During  this  period  the  vesical  mucosa 
often  shows  an  increased  vascularization,  or  more  or  less  congestion. 
Scattered  diffusely  over  the  mucosa  are  little  islands  of  mucus.  In 
the  more  severe  forms  the  exact  duplicate  of  the  mucous  patch  may 


isj          SY  i'n  /  us  <>{•  mi':  <;I-:MTO  URINARY  ORGANS 

occur;  this  may  he  multiple  and  become  so  extensive  as  to  form  distinct 
ulcers. 

TI.KTI  \i;v  SVIMIH.IS.  .  dji .  (lunima  of  the  bladder  occurs  especially 
in  iniddie  life,  thirty-five  to  fifty  year-  of  a  ire,  but  may  occur  earlier 
or  later. 

1.  rains  are  variable,  intermittent  or  continued,  or  radiating  at 
times,  increased  on  dee])  pressure,  little  marked  if  the  lesions  lie  on  the 
ba>e  of  the  bladder;  much  more  marked  at  the  time  of  micturition  if 
they  lie  at  the  vesical  neck. 

I'.  Ilematiiria  is  the  most  constant  and  important  symptom.  There 
may  be  a  terminal  hematuria,  intermittent,  hematuria,  or  a  con-taut 
hematnria,  lasting  from  the  beginning  to  the  end  of  urination.  This 
may  be  scant  or  profuse,  repeating  at  irregular  intervals,  often  acting 
in  a  peculiar  manner,  capricious  at  times,  as  in  hemorrhages  due  to 
ueoplasms. 

:'..  1'ollakiuria  is  a  frequent  symj)toin;  the  urine  almo-t  always  con- 
tains a  large  quantity  of  red  cells  and  leukocytes  rarely  have  any 
organisms  been  found. 

As  a  rule  the  general  ])hysical  condition  is  little  affected. 

CystofCOpic  F..ra  initiation.  Tertiary  syphilis  manifests  itself  on  the 
vesical  mucous  coat  in  two  ways: 

ricerations. 
(6)  Papillomata. 

The  diagnosis  of  liberations  is  not  difficult;  they  may  be  rounded, 
more  or  le-s  extended,  isolated  or  multiple;  they  make  projections  into 
the  vesical  cavity,  the  edges  are  infiltrated,  cut  into  peaks,  and  the  ba-e 
is  generally  covered  with  a  yellow,  ])urulent  in 

Sometimes  these  lesions  appear  as  veritable  tumors.  sessile  or  pedun- 
culated,  capable  of  simulating  absolutely  the  character  of  a  fringed 
polypus  or  a  series  of  unequally  enlarged  papillomata;  they  may  In- 
found  in  the  region  of  the  triu'oin-.  around  the  \e-ical  neck,  seemini;  at 
times  to  continue  into  the  urethra. 

It  must  not  be  forgotten  that  syphilis  of  the  bladder  may  have  its 
course  quite  independent  of  other  syphilitic  manifestations.  The  most 
varied  forms  will  be  ob-erved,  from  Simple  hyperemia  of  the  mucous 
membrane  to  extended  breaking  down  of  ^ummatoiis  tissue. 

Diagnosis. —  Srcotularti  and  Trrfiart/  Si/j>hilix.  —  Syj)lulis  may  a  fleet 
the  bladder  as  well  as  any  other  part  of  the  body,  but  there  is  no  .such 
thing  as  chancre  of  the  bladder.  Syphilitic  affections  of  the  bladder 
that  produce  severe  destructive  symptoms  belong  to  the  tertiary 
period. 

Syphilitic  nlceration  of  the  bladder  mucous  membrane  may  be  soli- 
tary or  appear  at  the  same  time  with  syphilis  of  the  skin  and  other 
mucous  membranes. 

During  the  secondary  stage  of  the  disease  on  the  mucous  membrane 
of  the  bladder  may  be  found  a  general  or  localixed  eruption,  which  may 
be  in  the  form  of  ulcerous  processes  resembling  mucous  patches. 

It  is  easy  to  mistake  their  etiology,  particularly  gummas  that  simulate 


.N Y  I'll  I  us  »r  THI-:  />•/..  !/>/;/./,'  183 

papilloma  and  single  ulcer-.  beeau-e  a  gumma  may  he  transformed  into 
ningly  .single  ulcer  l>y  central  necr 

Jt  is  often  difficult  to  distinguish  gummas  from  papilloma,  so 
that  their  syphilitic  nature  can  only  l>e  recogni/ed  by  simultaneous 
appearance  of  syphilitic  ulcers  either  in  the  bladder  or  other  part-  of 
the  body,  or  by  the  prex-nce.  of  M.IIIC  other  tertiary  legion. 

These  ulcers  may  extend  deep  and  lead  to  perforation  of  the  bladder 
peritoneum  or  to  ve-ieo\  aginal  fistuhe. 

It  is  well  in  every  case  of  papilloma  to  get  a  thorough  history  of  the 
patient,  and  make  careful  and  thorough  examination  of  the  skin  and 
other  organ-. 

Simple  solitary  ulcers  >hoiild  arouse  suspicion  of  syphilis,  especially 
if  tuberculosis  can  be  excluded  by  bacteriological  examination.  Syphil- 
itic ulcers  can  be  distingui.-hed  from  ordinary  or  tuberculous  ulcers  by 
the  infiltrated  edges  which  project  more  or  le-s  into  the  ulcer  cavity. 

As  MM, ii  as  a  Mi-picion  of  syphilis  is  aroii>ed  a  \Va-sermann  examina- 
tion should  be  made  by  a  reliable  serologist,  all  local  treatment  should 
be  discontinued  ami  specific  treatment  instituted. 

The  gummas  generally  cau>e  symptoms  of  new  growth  and  hemor- 
s  which  are  not  influenced  by  re-t  or  ot  her  treatment.  Hemorrhages 
from  gumma  may  last  from  the  beginning  to  the  end  of  urination,  while 
hemorrhages  in  ulcers  of  the  bladder,  even  if  syphilitic,  are  terminal. 

1  leers  are  more  apt  to  cause  pyuria  than  gumma. 

The  number,  si/e  and  loca t ion  of  the  lesions,  either  gummas  or  ulcers, 
greatly  influence  the  accompanying  symptomatology. 

Treatment.  It  must  not  be  forgotten  that  vesical  syphilis,  whether 
secondary  or  tertiary,  is  only  an  incident  in  the  course  of  a  general 
syphilitic  infection  and  that  after  the  \  e-ical  lesions  are  healed,  every 
effort  known  to  modern  medicine  should  be  made  to  safeguard  the 
patient  from  a  relapse  in  other  organs. 

The  Wassermann  reaction  offers  the  best  and  most  efficient  guide 
in  the  management  of  syphilitic  cases.  Unfortunately,  the  tendency 
is  to  give  too  little  treatment  and  to  stop  when  the  first  negative 
reaction  is  reached. 

I  nder  the  new  therapy  (salvarsan  and  mercury)  all  cases  that  come 
under  observation  should  be  treated  at  least  nine  months  after  the 
negative  goal  is  reached,  giving  during  this  period  150  rubbings  of 
mercury  and  at  least  two  intravenous  injections  of  salvarsan.  It  must 
be  distinctly  understood  that  treatment  should  be  continued  vigorously 
during  the  "  negative  phase,"  in  order  to  secure  permanent  results. 

Salvarsan  given  every  week  or  ten  days  for  four  or  five  doses,  then 
every  month,  with  mercury  rubbings,  controlled  by  biological  examina- 
tions, constitute  the  best  method  of  treating  the  patient.  It  should 
be  borne  in  mind  that  dilatory  and  haphazard  treatment,  while  healing 
the  lesions,  often  produces  both  a  salvarsan-  and  mercury-fast  spirochete 
which  when  localized  in  other  regions  (spinal  fluid)  may  never  be 
dislodged. 

Spinal  fluid  examinations,  while  appearing  superfluous,  are  as  much 


184  SYPHILIS  ni'   THE  cKMTu  r/,'/.\  .l/.T  ORGANS 

indicated  here  as  in  other  forms  of  visceral  syphilis,  and  a  physician 
with  the  patient's  best  interests  at  heart  should  certainly  in>i>t  on 
making  them. 

Spinal  Cord  Affections  Simulating  Bladder  Disease. — Besides  these 
secondary  and  tertiary  syphilitic  diseases  of  the' bladder  there  are 
considerable  number  of  ca>es  that  come  under  observation  on  account 
of  spinal  cord  disease  (progressive  paralysis  and  tab' 

Unfortunately  a  Wassermauu  reaction  on  the  blood  is  not  the  last 
word  in  diagnosis,  as  it  is  often  negative  in  this  class  of  infections; 
unless  a  spinal  fluid  examination  is  made  the  true  cause  of  the  trouble 
may  be  overlooked  until  the  degeneration  has  gone  so  far  that  restora- 
tion of  function  is  not  possible. 

While  it  is  true  that  trabeculization  of  the  bladder  without  other 
known  cause  of  obstruction  should  eau>e  a  strong  suspicion  of  syphilis, 
especially  in  the  absence  of  other  nerve  degeneration  findings,  a  spinal 
puncture  should  not  be  neglected. 

Many  of  tin  .  on  account  of  treatment  and  catheteri/.ation. 

proent  mild  grades  of  cystitis;  the  cy>toscopi<:  picture  is  therefore 
altered  and  a  diagnosis  is  impossible  with  the  cystoscope. 

Treatment. — While  practically  hopeless  in  the  advanced  cases,  much 
can  be  done  if  the  condition  is  diagnosed  early.  Here,  as  in  other  forms 
of  syphilitic  lesions,  regular,  persistent  treatment  by  the  Swift-Kllis 
method,  or  the  combined  method  of  salvarsin  and  mercury,  if  given 
intensively  after  the  method  of  ( 'ollins,  is  most  satisfactory,  the  treat- 
ment being  controlled  by  serological  examination  of  the  blood  seruin 
and  the  spinal  fluid. 

SYPHILIS  OF  THE  URETER. 

Syphilis  of  the  ureter  i>  rare.  A  case  has  been  described  by  1  hidden, 
as  mentioned  by  Osier  and  (Jibsoii. 

While  involvement  of  the  ureter  has  been  observed  in  conjunction 
with  bladder  syphilis,  it  is  impossible  to  recogni/e  this  condition  alone 
except  at  autopsy. 

Essential  Hematllria. — While  a  great  deal  of  speculation  has  been 
brought  forward  in  regard  to  the  etiological  factors  in  essential  hema- 
turia,  few  have  considered  the  possibility  here  of  secondary  ulcers 
or  gununatous  formation,  and  it  might  be  well  in  this  class  of  cases 
to  thoroughly  eliminate  this  form  of  infection  before  ascribing  some 
doubtful  etiology. 

SYPHILIS  OF  THE  KIDNEY. 

Syphilitic  nephritis  manifests  itself  in  the  following  forms: 

1.  Acute  parenchymatous  syphilitic  nephritis. 

2.  Chronic  interstitial  nephritis. 

3.  Amyloid  kidney. 

4.  Gummatous  kidney. 


S   01'    Till':    KtDM'Y  185 


Under  this  heading  will  be  considered  only  those  forms  of  syphilitic 
infection  in  which  the  symptoms  and  pathology  can  he  actually 
attributed  to  the  Spirocha-ta  pallida,  the  first  and  the  fourth. 

Acute  Parenchymatous  Syphilitic  Nephritis.  Synonyms.  —  Acute 
early  syphilitic  nephritis;  nephritis  syphilitica  pra-cox. 

The  first  to  acknowledge  syphilitic  kidney  diseases  was  Bayer.17 
lie  wrote  as  follows:  "  I  liave  seen  cases  in  which  the  influence  of  con- 
stitutional venereal  diseases  seemed  so  striking  that  I  did  not  hesitate 
to  attribute,  at  least  to  a  great  extent,  the  development  of  kidney 
diseases  to  the  venereal  cachexia." 

The  first  description  of  kidney  syphilis  was  given  by  Virchow.63 
lie  observed  that  simple  nephritis  is  often  found  in  syphilitics,  but 
that  does  not  justify  considering  them  specific,  because  they  have  no 
characteristic  signs. 

(lniol:>l)  published  the  first  report  of  syphilitic  albuminuria  and 
Perodu57  the  first  description  of  early  acute  syphilitic  nephritis. 

Karvonen  -  and  Neumann15  are  among  the  writers  on  the  subject. 
More  recently,  Bauer,1'1  Habetin,  Erich  Hoffmann,61  Osthelder,56 
Welz,64  Tach/'2  Morit/'5  and  I>ama-k  '  have  written  communications, 
while  the  excellent  monograph  of  Mnnk  '  ranks  as  an  authority  on  the 
subject. 

Owing  to  the  fact  that  the  causative  airent  in  syphilis  was  so  long 
misunderstood,  few  realize  that  during  the  period  of  secondary  localiza- 
tion (secondary  eruption),  the  spirochetes  are  actually  present  in  every 
organ  of  the  human  body  to  a  greater  or  less  extent,  and  the  fact  that 
syphilis  may  cause  disease  of  the  internal  organs  during  the  eruption 
of  the  first  exanthem  or  even  for  some  time  before,  is  recognized  possibly 
by  syphilologists  alone. 

Hoffmann  lias  shown  that  transmissible  spirochetes  circulate  in  the 
blood  three  weeks  before  the  outbreak  of  the  eruption. 

For  a  long  time  there  has  been  a  great  deal  of  doubt  concerning  the 
specific  nature  of  the  nephritis  appearing  in  the  early  stage.  Sena- 
tor,59 co  an  expert  himself  on  kidney  diseases,  did  not  admit  the  real 
nature  of  this  condition  in  1902. 

We  are  astonished  to  find  that  today  a  great  number  of  cases  of 
disease  of  the  heart,  bloodvessels,  liver,  kidney  and  joints  in  syphilitics 
are  due  to  the  Spirochaeta  pallida,  yet  more  surprising  is  the  number  of 
syphilitics  who  do  not  know  that  they  are  affected.  It  has  only  been 
in  the  last  ten  years  that  the  syphilitic  etiology  in  many  cases  of  aortic 
aneurysm  has  been  recognized. 

In  Munk's  clinic,  among  260  cases  of  visceral  syphilis  with  a  strongly 
positive  Wassermann,  38  per  cent,  of  the  men  and  84  per  cent,  of  the 
women  did  not  know  that  they  had  the  infection. 

Notwithstanding  the  advance  in  our  knowledge  of  visceral  syphilis, 
the  subject  has  been  more  clearly  understood  only  since  the  introduction 
of  the  Wassermann  reaction  in  practice. 

Etiology.  —  This  form  of  nephritis  is  a  hematogenous  injury,  not  a 
tissue  process,  and  it  is  caused  by  the  presence  of  the  Spirochseta  pallida. 


ISC.  SYPHILIS  OF   THE  GEN  I  TO-URINARY  ORCAXS 

By  most  authors,  therefore,  syphilitic  nephritis,  as  well  as  nephritis 
caused  by  scarlet  fever  and  other  infectious  diseases,  is  attributed  to  a 
toxic  cause.  The  idea  that  the  continued  administration  of  mercury  in 
syphilitics  causes  a  nephritis  has  long  been  held. 

The  question  of  whether  the  kidney  injury  in  these  cases  is  due  to 
syphilis  or  to  mercury  is  decided  at  once  by  the  lipoid  findings  in  the 
urine,  reference  to  which  will  be  made  later.  In  the  nephritis  caused  by 
mercury  there  is  never  lipoid  degeneration,  therefore  no  lipoid  casts  are 
found  in  the  urine. 

Naturally  there  are  all  sorts  of  transitional  forms,  from  very  severe 
cases  of  nephritis  to  slight  and  quickly  passing  albuminurias,  which 
many  syphilographers,  especially  the  French,  maintain  are  very  fre- 
quent, but  according  to  Hoffmann,  are  rare  in  Germany. 

Since  the  discovery  of  the  Spirochseta  pallida  we  are  in  a  position 
to  test  its  relation  to  the  kidney.  In  these  investigations  it  has  been 
frequently  found  in  the  kidneys  of  congenitally  syphilitic  children. 
They  have  been  reported  as  having  been  found  in  the  urine  in  cases  of 
acquired  syphilis. 

Recent  syphilis  can  generally  be  demonstrated  by  the  clinical  symp- 
toms; however,  these  may  be  so  masked  by  severe  edema  that  they 
are  not  apparent.  It  is  more  difficult  to  palpate  the  glands,  and  even 
the  eruption  is  not  so  easy  to  recognize  on  an  edematous  skin.  There- 
fore it  is  particularly  important  to  make  a  diagnosis  either  by  finding 
the  spirochetes  in  the  urine  or  by  the  Wassermann  reaction. 

From  Hoffmann's  experience  in  determining  the  syphilitic  etiology  in 
a  given  case,  and  from  the  recent  advances  in  syphilology,  he  formu- 
lated the  following  signs  as  an  indication  of  early  syphilitic  nephritis: 

1.  The  demonstration  of  recent  syphilis  by  clinical  symptoms,  finding 
the  Spirochseta  pallida  in  primary  or  secondary  lesions,  and  a  positive 
Wassermann  reaction. 

2.  Characteristic  signs  in  the  urine,  such  as  enormous  albumin  con- 
tents, and  the  finding  of  the  Spirochseta  pallida  in  the  sediment  of  the 
urine  removed  by  catheterization. 

3.  The  influence  of  specific  treatment,  which  is  almost  always  evident 
if  mercury  and  salvarsan  are  correctly  used. 

According  to  Hoffmann,  acute  syphilitic  nephritis  may  develop  in 
two  ways:  either  gradually,  without  any  specific  symptoms,  so  that  it 
may  be  overlooked  unless  the  urine  is  examined,  or  in  a  more  or  less 
stormy  fashion,  with  marked  edema  and  fluid  in  the  body  cavities. 
However,  most  patients  seek  the  physician's  advice  on  account  of 
general  edema  and  weakness;  this  gradually  progresses  and  anemia 
may  be  marked. 

The  principal  and  most  characteristic  symptom  is  the  anemic  appear- 
ance of  the  patient,  with  a  more  or  less  severe  edema;  the  patients 
complain  of  a  great  weariness  and  weakness;  sometimes  there  is 
difficulty  in  breathing;  headaches  are  not  very  frequent;  vomiting,  as 
a  rule,  appears  late,  as  well  as  other  uremic  symptoms. 

As  long  as  there  is  no  complication,  fever  rarely  goes  higher  than  38° 


PLATE   II 


»mm 


Acute  Parenchymatous  Syphilitic  Nephritis.     (Munk.; 


SYPHILIS  OF  THE  KIDNEY  187 

to  38.5°  C. ;  chills  are  not  present.     The  only  symptom  that  the  patient 
complains  of  is  that  on  urinating  he  notices  a  small  amount  of  urine. 

Urinary  Findings. — These  are  especially  characteristic.  The  vol- 
ume varies  from  300  to  1200  c.c.;  the  color  is  normal  yellow,  reaction 
acid,  specific  gravity  very  high;  albumin  contents  generally  high,  up  to 
28  per  1000.  Microscopically,  examination  of  the  urinary  sediment 
shows  a  small  number  of  red  cells,  fairly  numerous  white  cells,  many 
epithelial,  and  a  few  hyaline,  waxy  and  granular  casts,  but  most  of  them 
lipoid  casts.  Under  the  polarizing  microscope,  in  fresh  specimens  the 
whole  field  may  be  strewn  with  double  refracting  drops,  some  of  them 
in  crystalline  form  and  some  of  them  cylindrical. 

Recently,  Stengel  and  Austin,61  in  this  country,  have  examined  the 
urine  with  a  polarizing  microscope  fifty-eight  times  in  46  cases.  Of 
the  46  cases,  23  showed  nephritis  with  an  abundance  of  albumin  and 
casts  in  the  urine.  Of  these  23  cases,  6  had  positive  Wassermanns; 
3  had  strong  presumptive  evidence  of  syphilis,  but  not  positive  Wasser- 
mann.  Fourteen  had  not  the  slightest  evidence  of  syphilis.  The  6 
cases  with  the  positive  Wassermann  all  showed  lipoids  in  the  urine, 
whereas,  in  the  14  non-syphilitic  cases  only  5  showed  lipoids  in  the  urine. 

Pathology. — According  to  Munk,  the  pathological  anatomy  of  this 
form  of  syphilitic  kidney,  at  the  height  of  the  disease,  corresponds  to 
the  co-called  large  white  kidney,  which  name  has  been  given  it  on 
account  of  its  macroscopic  appearance.  The  color  is  really  not  white, 
but  a  grayish  yellow,  due  to  the  lipoid  contents  and  the  cloudy  swelling 
of  the  cortical  substance. 

The  kidney  for  the  most  part  is  flaccid  and  soft.  On  the  surface 
of  the  kidney  it  is  possible  to  see,  at  times,  individual  groups  of 
convoluted  tubules  appearing  as  yellow  flecks  standing  out  from  the 
remaining  grayish-yellow  turbid  ground  substance. 

On  cross-section  the  cortical  substance  seems  increased  in  breadth 
and  so  swollen  that  it  stands  out  over  the  medullary  substance.  The 
medullary  rays  may  be  recognized  as  gray,  watery  stripes,  often  com- 
pletely transparent  and  gelatinous,  while  the  cortical  pyramids  appear 
turbid,  intersected  by  bright  yellow  stripes  and  flecks  which  are  the 
convoluted  tubules  which  have  undergone  fatty  degeneration.  The 
vessels  are  not  wrell  filled,  while  the  vasa  recta  of  the  medullary 
substance  are,  so  that  there  is  a  sharp  contrast  in  the  coloring  of 
the  two  substances.  Plate  II  gives  a  picture  of  a  frozen  section  of 
such  a  kidney  colored  with  sudan  hamalaun.  The  lipoids  are  colored 
yellowish  red ;  wre  see  the  convoluted  tubules  chiefly  attacked  by  the 
lipoid  degeneration.  Besides  the  lipoid  degeneration,  some  parts  of  the 
convoluted  tubules  show  a  somewhat  indistinct  appearance.  These 
are  in  a  state  of  cloudy  swelling.  The  glomeruli,  are,  on  the  contrary, 
completely  intact.  The  nucleus  stains  well  and  the  interstitial  tissue  does 
not  show  any  changes  which  indicate  inflammatory  processes,  either 
cellular  infiltration  or  productive  proliferation.  We  have,  therefore, 
an  organ  which  has  undergone  a  purely  degenerative  change.  The 
cloudy  swelling  itself  is  a  degenerative  stage  which  may  pass  over  into 


188  SYPHILIS  OF   THE  GEN  I  TO-URINARY  ORGANS 

fatty  or  lipoid  degeneration.  A  noteworthy  fact  is  the  rapid  appear- 
ance of  primary  lipoid  degeneration  of  the  kidney  epithelium,  without 
any  further  degenerative  or  later  inflammatory  changes. 

Clinically,  this  type  of  syphilitic  kidney  is  an  acute  nephritis,  but  from 
the  point  of  view  of  pathological  anatomy,  it  is  a  degenerative,  non- 
inflammatory change  of  the  organ  of  a  chronic  character,  and  can  be 
set  in  a  group  by  itself  as  a  form  of  degenerative  kidney  disease  peculiar 
to  syphilis  (Munk). 

Symptoms. — The  leading  symptoms  of  nephritis  following  infectious 
diseases  are:  marked  anemia  and  a  considerable  degree  of  dropsy, 
which  is  a  dropsy  of  the  body  cavities  rather  than  a  general  anasarca, 
as  in  syphilis.  Headache  and  rise  of  temperature  are  only  exceptionally 
observed  in  uncomplicated  cases.  Marked  uremia  is  unusual  if  there 
is  not  a  considerable  degree  of  stasis;  the  liver  and  spleen  are  involved 
only  moderately,  if  at  all.  Murmurs  may  be  demonstrated  in  the  heart 
from  time  to  time,  but  they  are  generally  due  to  anemia.  Accentua- 
tion of  the  second  aortic  sound  is  rare,  at  least  in  the  beginning,  and 
at  that  time  there  are  no  signs  of  increased  blood-pressure. 

The  symptoms  of  nephritis  may  appear  in  a  few  months,  or  not  until 
some  years  after  the  infection.  The  Wassermann  reaction  may  be 
strongly  positive  or  only  weakly  positive.  However,  a  positive  Wasser- 
mann reaction  is  not  sufficient  to  decide  the  question  whether  in  a  given 
case  we  have  a  syphilitic  nephritis  or  merely  nephritis  in  a  syphilitic 
patient,  but  it  fills  the  gap  in  the  history  of  patients  who  do  not  know 
that  they  have  the  disease,  and  it  increases  the  number  of  demon- 
strable syphilitic  cases  in  which  the  nephritis  is  observed. 

Urinary  Findings. — These  are  of  the  greatest  importance.  The 
daily  amount  is  small,  sometimes  as  little  as  300  c.c.  The  urine  is 
turbid,  yellow  or  brown  in  color  and  macroscopically  only  rarely  shows 
blood.  The  reaction  is  always  acid,  specific  gravity  high,  sediment 
abundant.  Its  chief  constituents  are  double  refracting  lipoid  sub- 
stances which  are  sometimes  free  in  individual  droplets  or  clumped 
together,  or  they  may  appear  as  fine  droplets  in  the  numerous  epithelial 
cells,  but  a  more  characteristic  formation  is  that  of  large  opaque  casts. 
Pure  hyaline  and  granular  casts  are  found,  but  they  are  rare.  There 
are  also  considerable  numbers  of  leukocytes,  the  mononuclear  form 
predominating. 

It  is  true  that  lipoid  substances  occur  in  the  urinary  sediment  in 
secondary  contracted  kidney,  but  not  in  such  amount  as  in  parenchy- 
matous  syphilitic  kidney,  and  the  albumin  contents  also  are  lower. 

Munk  says  that  greater  difficulties  lie  in  differentiating  this  form  of 
kidney  from  large  white  amyloid  kidney.  The  urinary  findings  are 
quite  similar,  but  the  amyloid  kidney  is  distinguished  by  the  fact  that 
in  addition  to  lipoids  it  has  relatively  numerous  single  refracting  fat 
elements.  These  two  forms  of  disease  are  different  also  in  the  time  of 
their  appearance.  While  amyloid  kidney  generally  develops  slowly, 
still  it  leads  to  severe  clinical  symptoms;  syphilitic  disease  appears 
early  with  very  severe  symptoms,  especially  marked  dropsy.  Within 


SYPHILIS  OF   THE  KIDNEY  189 

ten  days  after  the  first  appearance  of  albumin  in  the  urine,  the  condition 
may  become  threatening. 

Munk  hopes  that  this  form  of  acute  parenchymatous  degenerative 
kidney  will  be  more  often  recognized  in  the  future,  since  it  can  be  recog- 
nized only  by  means  of  examination  of  the  sediment  by  the  polarizing 
microscope. 

Unfortunately,  most  cases  that  come  to  the  medical  clinics  have 
severe  symptoms,  and  as  a  consequence  this  makes  the  number  of  cases 
appear  relatively  small,  but  there  is  no  doubt  that  there  are  a  large 
number  of  cases  with  mild  symptoms  that  are  observed  and  treated  by 
syphilographers. 

Differential  Diagnosis. — Differential  diagnosis  can  be  made  between 
acute  parenchymatous  syphilitic  nephritis  and  nephritis  resulting  from 
other  infectious  diseases. 

Prognosis. — In  most  cases,  with  proper  treatment  and  care,  the 
patients  recover  from  the  first  stage,  even  when  there  has  been  high- 
grade  edema  and  weakness  of  .threatening  character.  The  edema  may  last 
two  or  three  weeks,  or  may  disappear  earlier,  sometimes  very  rapidly. 
The  quantity  of  urine  increases,  the  formed  constituents  in  the  urine 
decrease,  but  the  albumin  contents  remain  rather  high.  As  soon  as 
the  edema  disappears  completely,  the  patient  usually  regains  his 
strength  and  appetite  and  normal  conditions  return.  The  headaches 
gradually  pass  away.  The  amount  of  urine  may  vary  for  awhile  in  the 
formed  elements;  especially  lipoids  may  be  observed  from  time  to 
time,  but  it  is  the  high  albumin  contents  that  may  persist  for  months 
afterward,  rising  and  falling  indefinitely. 

The  relatively  benign  course  of  acute  parenchymatous  syphilitic 
nephritis  is  surprising,  and  like  all  other  forms  of  syphilitic  infection, 
the  prognosis  depends  on  the  prompt  diagnosis,  for  the  longer  the 
kidneys  remain  jammed  with  spirochetes  with  their  attending  sys- 
temic symptoms,  the  more  difficult  will  it  be  to  bring  about  permanent 
resolution. 

According  to  Munk's  views,  a  fatal  outcome  in  the  acute  stage  is  very 
rare  in  spite  of  the  severe  symptoms,  such  as  dropsy,  anemia,  weakness, 
and  so  forth. 

Hoffmann  says:  "The  prognosis  of  early  acute  syphilitic  nephritis, 
which  was  good  before,  has  become  even  better  since  the  introduction 
of  salvarsan." 

We  have  two  powerful  remedies,  both  without  danger  if  properly 
used.  In  the  majority  of  cases  the  albuminuria  is  completely 
overcome.  Death  is  rare  and  when  it  occurs  is  perhaps  due  to 
improper  treatment.  The  quick  cure  is  due  to  the  double  action  of 
salvarsan  and  mercury  against  the  spirochetes  through  the  blood  and 
urinary  tubules. 

Treatment. — In  every  case  of  syphilis  which  is  presented  for  examina- 
tion and  treatment  a  careful  urinalysis  should  be  made,  and  if  later  on 
an  albuminuria  presents  itself,  its  etiology  will  not  be  so  obscure.  If  a 
patient  comes  for  treatment  at  the  height  of  his  disease,  it  is  generally 


190  SYPHILIS   OF    THE   GEXITO-URIX  ARY  ORGANS 

extreme  dropsy  and  oliguria  that  demand  attention.  As  this  condi- 
tion is  caused  by  the  presence  of  the  Spirochseta  pallida  within  the 
substance  of  the  kidney,  as  soon  as  specific  remedies  can  be  applied 
(salvarsan  and  mercury),  thecondition  should  improve.  Unfortunately, 
diuretics  do  harm;  the  chemical  irritation  caused  by  them  causes 
the  degenerated  epithelium  to  be  discharged  suddenly  and  in  large 
quantities.  Such  a  considerable  desquamation  of  kidney  elements  is 
not  without  danger  for  future  restoration  of  the  kidney.  Diuretics,  if 
used  at  all,  should  be  of  the  mildest  form;  diuresis  should  be  taken  care 
of  in  a  compensatory  manner  by  free  saline  catharsis.  Whenever  the 
anasarca  has  advanced  to  a  considerable  degree,  skin  drainage  may  be 
resorted  to. 

As  soon  as  possible  small  doses  of  salvarsan  should  be  given.  It  is 
perhaps  best  not  to  give  over  0.2  gin.  or  0.3  gm.  at  a  dose,  and,  as  soon 
as  the  dropsy  has  disappeared,  rubbings  may  be  combined. 

Hoffmann  gives  salvarsan  the  preference  in  nephritis.  It  does  not 
cause  irritation  of  the  kidneys,  except  in  very  rare  cases.  Some  authors 
hold  that  it  is  sufficient  to  cure. 

The  dietetic  management  in  this  class  of  cases  deserves  some  little 
attention.  Eggs,  milk  and  carbohydrates  are  used  as  an  exclusive  diet 
in  the  beginning.  Munk  recommends  some  form  of  malt  extract  to 
be  added  to  the  milk,  and,  on  account  of  the  severe  anemia,  iron  is 
given  as  soon  as  the  intestinal  tract  will  stand  it.  Meat  should  not  be 
withheld  long. 

The  use  of  baths  and  hot  packs  is  contra-indicated  in  this  form  of 
nephritis,  because  the  advantage  to  be  gained  from  them  is  not  in 
proportion  to  the  bad  effects  they  have  in  increasing  the  general 
weakness. 

The  general  specific  treatment  for  the  syphilitic  condition  must,  of 
course,  be  carried  on,  regularly  controlled  by  the  ^Yassermann  reaction. 

CONCLUSIONS. — Munk's  conclusions  are  the  following: 

In  the  clinical  diagnosis  of  nephritis  more  attention  must  be  paid 
than  heretofore  to  the  different  degenerative  processes  in  the  kidney. 

The  examination  of  the  urine  may  give  valuable  information  on 
this  point. 

The  demonstration  of  fat  and  fat-formed  elements  in  the  urine  points 
to  a  fatty  degeneration  of  the  organ  in  the  different  forms  of  cachexia. 
The  presence  of  a  greater  or  less  amount  of  fat-formed  elements  shows 
the  destruction  of  kidney  parenchyma  in  acute  forms  of  nephritis. 

The  demonstration  by  means  of  the  polarization  microscope  of 
double  refracting  lipoids  in  the  sediment  of  the  urine  is  a  reliable 
criterion  for  differential  diagnosis  between  acute  inflammatory  and 
chronic  degenerative  kidney  diseases. 

GUMMA  OF  THE  KIDNEY. 

Gumma  of  the  kidney  is  rarely  recognized  except  at  autopsy. 

It  wTas  Arnold  Beer48  who  gave  the  first  description  of  gumma  of  the 


GUMMA   OF  THE  KIDNEY  191 

kidney.  Gummatous  disease  of  the  kidney  generally  appears  in  the 
form  of  circumscribed  miliary  nodules  varying  in  size  from  that  of  a 
grain  of  millet  to  that  of  a  hazel-nut,  which,  as  a  rule,  are  limited  to  one 
kidney.  They  generally  occur,  in  the  cortical  substance,  extending  at 
times  more  or  less  deeply  into  the  medullary  substance,  even  as  deep 
as  the  papillae.  Occasionally  a  single  gumma  occurs,  but  usually  they 
are  multiple. 

On  section  these  gummata  show  a  peripheral  part  which  is  gray 
and  transparent.  They  may  be  either  soft  or  hard,  with  a  necrotic 
centre  consisting  of  caseous  masses  undergoing  fatty  degeneration. 
The  periphery  consists  of  tissue  which  is  rich  in  cells  and  vascular  tissue. 
In  this  tissue,  or  sometimes  surrounded  by  it,  there  are  atrophied 
urinary  tubules,  together  with  shrunken  Malpighian  bodies. 

When  these  gummata  have  evacuated  their  contents,  they  may  be 
resorbed  by  the  lymphatics  of  the  kidneys,  and,  when  superficial,  leave 
in  their  places  cicatrices  with  corresponding  deformities. 

Symptoms. — As  in  gummata  elsewhere,  gummata  of  the  kidney 
manifest  themselves  from  seven  to  twenty  years  after  the  chancre  first 
appears.  The  evolution  of  the  gumma  is  slow  and  insidious  and  only 
exceptionally  gives  symptoms  which  permit  of  a  diagnosis  during  life. 
In  some  cases,  however,  gummata  that  open  into  the  pelvis  of  the 
kidney  may  soften  and  discharge  their  contents  into  the  urine.  As 
soon  as  this  elimination  of  the  contents  occurs,  the  urine  again  be- 
comes macroscopically  clear,  the  condition  remaining  undiagnosed, 
thus  leaving  the  true  cause  unsuspected. 

Gummatous  kidney,  when  greatly  enlarged,  may  simulate  a  malignant 
tumor.  In  such  instances,  even  in  the  absence  of  positive  symptoms 
of  syphilis,  a  Wassermann  reaction  may  clear  up  a  doubtful  diagnosis. 
The  possibility  of  a  tuberculous  kidney  should  be  constantly  kept 
in  mind. 

Prognosis. — Unless  the  attending  interstitial  nephritis  is  advanced, 
the  prognosis  is  good. 


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192  SYPHILIS  OF   THE  GEXITO-URIXARY  ORGANS 

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48.  Beer,  A.:  Die  Eingeweide  Syphilis,  Tubingen,  1867. 

49.  Damask:  Mitt.  d.  Gesellsch.  f.  inn.  Med.  u.  Kinderheilk.  in  Wien,  1912,  xi,  119. 

50.  Guiol,  V.  F. :  Sur  1'albuminurie  syphilitique,  These,  Paris,  1867. 

51.  Hoffmann,  Erich:  Deutsch.  med.  Wchnschr.,  1913,  xxxix,  353. 

52.  Karvonen,  J. :  Die  Nierensyphilis,  Berlin,  1901. 

53.  Moritz,  Alfred:  Beitrag  zur  Kenntnis  der  Nierensyphilis.    Diss.,  Heidelberg,  1912. 

54.  Munk,  Fritz:  Zeitschr.  f.  klin.  Med.,  1913,  Ixxviii,  24. 

55.  Neumann,  Isidor:    Syphilis.      Nothnagel's   spez.   Path.   u.  Therap.,  Wien,   1896, 
xxiii,  436. 

56.  Osthelder,  F.:  Vereinsbl.  d.  pfalz.  Aerzte,  1913,  xxix,  200. 

57.  Perodu:    De  l'albuminurie  dans  la  periode  secondaire,  de  la  syphilis,  Mem.  et 
compt.  rend,  de  la  Soc.  d.  sc.  med.  de  Lyon,  1867,  vi,  88,  196. 

58.  Power  and  Murphy:    System  of  Syphilis,  London,  1901,  iii,  79. 

59.  Senator:  Ueber    die    acut-infectiosen    Erkrankungsformen    der    constitutionellen 
Syphilis,  Berl.  klin.  Wchnschr.,   1902,  xxxix,  482. 

60.  Senator:  Erkrankungen  der  Nieren.      Nothnagel's  spez.  Path.  u.  Therap.,  Wien, 
1896,  xix. 

61.  Stengel  and  Austin:  Am.  Jour.  Med.  Sc.,  1915,  cxlix,  12. 

62.  Tach,  Jean:  A  propos  de  deux  observations  de  nephrite  precoce  ch6z  des  syphili- 
tiques,  These,  Bordeaux,  1913. 

63.  Virchow:  Virchows  Arch.,  1858,  xv,  217. 

64.  Welz,  A.:  Deutsch.  med.  Wchnschr.,  1913,  xxxix,  1201. 


SECTION    II. 

THE  PENIS  AND  IJEETHEA. 


CHAPTER  VI. 
ANATOMY,  ANOMALIES  AND  INJURIES  OF  THE  PENIS. 

BY  H.  A.  FOWLER,  M.D. 

ANATOMY  OF  THE  PENIS. 

THE  penis  is  the  male  organ  of  copulation.  'It  is  also  concerned  with 
urination.  It  therefore  has  a  double  function:  genital  and  urinary. 
Its  anatomical  structure  is  peculiarly  adapted  to  subserve  these  two 
functions.  It  is  composed  chiefly  of  erectile  tissue  separated  into 
three  parallel,  cylindrical  segments,  by  tough  fibre-elastic  investments. 
The  two  larger  segments,  the  corpora  cave*rnosa,  lie  side  by  side  on  the 
dorsal  surface  and  make  up  the  main  bulk  of  the  organ.  In  the  groove 
on  their  under  or  ve'ntral  surface  is  placed  the  third  or  smaller  segment, 
the  corpus  spongiosum,  wrhich  surrounds  the  urethra  and  expands 
distally  to  form  the  free  end  of  the  penis.  These  three  bodies  are  bound 
together  by  a  common  sheath  of  dense  fibro-elastic  tissue,  called  Buck's 
fascia,  and  the  whole  covered  by  integument  and  subcutaneous  layers. 
The  size  of  the  penis  varies  greatly  in  different  individuals  and  bears  no 
constant  relation  to  general  physical  development.  A  large  robust  man 
may  have  a  small  penis,  while  a  small  undersized  man  may  present  an 
organ  of  unusual  proportions.  The  average  length  of  the  penis,  when 
it  is  flaccid,  is  from  three  to  four  inches;  when  erect,  from  five  to  seven 
inches.  Its  circumference  is  about  three  inches. 

Corpora  Cavernosa. — The  corpora  cavernosa,  composed  of  erectile 
tissue,  are  closely  united  in  the  greater  part  of  their  extent.  They  arise, 
one  on  each  side,  in  the  form  of  a  dense,  flattened,  tendinous  attachment 
from  the  ascending  ramus  of  the  ischium.  They  converge  rapidly  and 
meet  just  in  front  of  the  arch  of  the  symphysis  pubis.  These  two 
extremities  form  the  root  of  the  penis,  and  are  called  the  crura  penis. 
The  anterior  extremities  are  separated  slightly  and  terminate  in 
rounded,  blunt  ends  which  fit  into  corresponding  depressions  on  the 
under  surface  of  the  glans  penis.  The  average  length  of  the  corpus 
cavernosum  is  six  inches;  its  diameter  one-half  inch. 

M  u.    i—13  (193) 


194     AX  ATOMY,   AXOMALIES  AXD   IX  JURIES  OF   THE   PEXIS 

They  are  invested  by  a  dense  fibre-elastic  sheath  or  tunica  albuginea. 
This  sheath,  according  to  Henle,  is  2  mm.  thick  when  the  penis  is  flaccid, 


hemispheres  of  bulb 
of  urethra 


corpus  cavernosunt  - 
of  urethra 


glans  penis  *- 


valve  of  navicular  fossa' 

external  orifice  of  urethra 


'  fossa  navicularis 


FIG.  112. — The  male  urethra  -with  the  corpora  cavernosa  of  the  penis,  the  bulbo-urethral 
glands,  and  the  prostate.      (Sabotta.) 

and  only  0.25  mm.  thick  during  erection.     It  is,  however,  remarkably 
tough  and  strong,  being  capable  of  supporting  the  entire  weight  of  the 


A. \*  ATOMY  OF   THE  PENIS  195 

body.  It  consists  of  two  layers:  an  outer,  of  longitudinal  fibers  com- 
mon to  both  bodies;  an  inner,  of  circular  fibers  surrounding  each  body 
separately  and  forming  a  median  partition,  the  septum  pectiniforme. 
This  septum  is  incomplete;  numerous  perforations  allow  free  inter- 
communication between  the  two  corpora,  thus  ensuring  symmetrical 
distention  during  erection. 

While  this  sheath  is  very  strong  it  is  also  very  elastic,  due  to  the 
predominance  of  elastic  tissue.  This  allows  for  the  great  variation  in 
size  during  repose  and  erection.  There  are  no  muscle  fibers  in  the 
tunica  albuginea.  The  angle  between  the  rounded,  anterior  extremities 
of  the  cavernous  bodies  is  filled  with  a  dense  fibrous  expansion  which 
projects  forward  into  the  glans  in  the  form  of  a  central  stalk  called  the 
anterior  ligament  of  the  corpora  cavernosa. 

The  inner  layer  of  the  tunica  albuginea  gives  off  numerous  fibrous 
septa,  some  thick  and  lamellated,  others  fine  and  filament-like,  which 
anastomose  freely  and  divide  the  inclosed  space  into  innumerable 
irregular  spaces  or  areolse.  These  trabecula  contain  unstriped  muscle 
fibers  in  addition  to  connective  tissue  and  elastic  fibers,  and  form  the 
supporting  framework  for  the  bloodvessels.  The  areola  spaces  thus 
formed  communicate  freely  with  each  other  and  with  those  of  the 
opposite  body  through  the  medium  of  the  septum.  They  are  lined  by 
endothelial  cells  and  represent  dilated  capillaries,  communicating  with 
the  afferent  artery  on  the  one  hand  and  the  efferent  veins  on  the  other. 
There  is  no  direct  vascular  communication  between  the  corpora  caver- 
nosa and  the  corpus  spongiosum  or  glans. 

Corpus  Spongiosum. — This  is  composed  of  erectile  tissue  similar 
in  structure  to  the  corpora  cavernosa.  It  presents  a  central  shaft  and 
two  expansions,  one  at  either  extremity.  The  posterior  dilated  ex- 
tremity, called  the  bulb,  lies  in  front  of  the  triangular  ligament  in  the 
angle  formed  by  the  converging  crura.  The  anterior  extremity  is 
expanded  into  a  cone-shaped  body,  the  glans  penis,  which  caps  the 
corpora  cavernosa.  The  glans  presents  at  its  posterior  border  a  flange- 
like  expansion,  the  corona  glandis.  Behind  this  is  a  deep  sulcus,  the 
coronary  sulcus  or  neck  of  the  penis.  The  urethra  perforates  the  corpus 
spongiosum  axially,  terminating  in  a  slit-like  opening  at  the  tip  of  the 
glans,  the  meatus  urinarius.  Within  the  bulb  the  urethra  is  not  cen- 
trally placed,  but  lies  nearer  the  dorsal  surface,  hence  a  greater  thick- 
ness of  spongy  tissue  covers  the  lower  or  ventral  aspect  of  the  urethra 
at  this  level.  In  the  glans  these  relations  are  reversed,  there  is  little  or 
no  erectile  tissue  below  or  ventral  to  the  urethra.  The  fibro-elastic 
sheath  surrounding  the  corpus  spongiosum  is  separate  and  distinct 
from  the  fibrous  investments  of  the  cavernous  bodies,  which  permits  the 
easy  dissection  of  the  former  from  the  latter. 

The  glans  is  usually  described  in  the  text-books  of  anatomy  as  the 
expanded  extremity  of  the  corpus  spongiosum,  hence  anatomically  and 
morphologically  a  part  of  this  body.  The  studies  of  Retterer  (1892) 
upon  the  development  of  the  penis  in  embryos  and  in  the  human  fetus 
of  different  ages  led  him  to  quite  different  conclusions.  According  to 


196     ANATOMY,  ANOMALIES  AXD  IN  JUKI  EX  OF  THE  PENIS 

this  author  the  spongy  body  surrounded  by  its  fibrous  elastic  sheath 
accompanies  the  urethra  as  far  as  the  meatus,  but  does  not  present  any 
expansion  at  its  anterior  extremity.  The  central  or  axial  portion  of  the 
glans  is  formed,  therefore,  of  the  anterior  extremities  of  the  corpora 
cavernosa  and  the  corpus  spongiosum.  This  is  surrounded  by  a  per- 
ipheral layer,  much  like  a  muff,  particularly  well  developed  dorsally, 
which  represents  the  cutaneous  and  fibrous  coverings  of  the  penis  at  this 
point.  Within  this  layer  the  terminal  branches  of  the  dorsal  arteries 
and  nerves  of  the  penis  end.  At  a  later  stage  of  development  this  per- 
ipheral layer  takes  on  the  structure  of  true  erectile  tissue  and  forms  the 
peripheral  portion  of  the  glans  in  the  adult.  Free  anastomosis  takes 
place  between  the  spongy  body  and  the  peripheral  layer  of  the  glans, 
while  the  vascular  connections  wifli  the  cavernous  bodies  are  small  and 
insignificant. 

Coverings  of  the  Penis. — The  coverings  of  the  penis  are  disposed 
in  four  layers.  From  without  these  are:  (1)  skin;  (2)  dartos;  (3) 
areolar  tissue;  (4)  fascia  of  the  penis.  The  skin  covering  the  penis 
differs  from  the  general  body  integument  in  its  freedom  from  fat,  the 
absence  of  smooth  muscle  fibers,  the  rudimentary  character  of  its 
sebaceous  glands,  and  the  absence  of  hair  except  at  or  near  the  base. 
It  is  remarkably  mobile,  and  after  puberty  is  pigmented,  resembling 
the  skin  of  the  scrotum.  Extending  beyond  the  glans  it  folds  back  on 
itself,  forming  a  hood-like  covering  of  the  glans,  called  the  prepuce. 
The  inner  semimucous  layer  of  this  duplicature  is  closely  adherent  to 
the  neck  of  the  penis  and  passes  forward  intimately  covering  the  glans, 
to  meet  the  mucous  membrane  of  the  urethra  at  the  meatus.  A  tri- 
angular fold,  the  frenum,  attaches  the  prepuce  to  the  glans  just  below 
the  meatus.  Tearing  or  rupture  of  the  frenum  is  often  accompanied 
by  severe  hemorrhage  from  the  frenal  artery,  which  is  controlled  only 
by  ligature.  This  artery  must  also  be  tied  whenever  the  frenum  is 
severed  during  circumcision.  The  two  layers  forming  the  prepuce  are 
separate  and  distinct,  thus  permitting  obliteration  of  the  preputial 
sac  and  uncovering  of  the  glans  by  retraction  of  the  skin.  Xumerous 
glands  on  the  inner  layer  of  the  prepuce,  particularly  about  the  frenum 
and  coronary  sulcus,  secrete  a  white  cheesy  material,  smegma,  with  a 
characteristic  offensive  odor. 

Immediately  beneath  the  skin  is  a  layer  composed  of  smooth  muscle 
fibers  continuous  with  the  dartos  of  the  scrotum.  The  fibers  run  for 
the  most  part  longitudinally,  others  have  an  oblique  direction.  This 
layer  extends  forward  to  the  preputial  orifice,  and  follows  the  inner 
layer  of  the  prepuce  as  far  as  the  neck  of  the  penis.  These  fibers,  by 
their  contraction,  are  supposed  to  assist  in  erection  by  producing  stasis 
in  the  superficial  veins. 

Beneath  the  dartos  is  a  layer  of  loose  areolar  tissue  rich  in  elastic 
fibers.  Within  this  layer  run  the  superficial  vessels  and  nerves.  It 
is  to  this  layer  that  the  skin  owes  its  extreme  mobility.  Its  loose 
texture  favors  the  excessive  accumulation  of  fluids  seen  in  massive 
edema  of  the  penis. 


ANATOMY  OF  THE  PENIS  197 

The  sheath  of  the  penis,  already  referred  to  as  Buck's  fascia,  is  com- 
posed almost  exclusively  of  elastic  tissue.  It  forms  the  common  sheath 
of  the  erectile  bodies  to  which  it  intimately  adheres.  It  is  attached 
posteriorly  to  a  triangular  bundle  of  fibers,  the  suspensory  ligament  of 
the  penis,  which  surrounds  the  penis  and  is  inserted  into  the  symphysis 
pubis,  and  to  the  superficial  perineal  fascia.  Anteriorly  it  is  inserted 
into  the  base  of  the  glans.  It  is  this  disposition  of  Buck's  fascia  which 
protects  the  cavernous  bodies  from  invasion  in  ulcerative  lesions  of  the 
glans,  and  also  by  confining  periurethral  inflammation  and  cellulitis  within 
its  limits  for  a  long  time  protects  the  glans  from  involvement. 

Muscles. — The  paired  muscles  of  the  penis  are  the  ischiocavernosus, 
or  erector  penis,  and  the  bulbocavernosus  or  accelerator  urinse.  The 
ischiocavernosus  arises  from  the  tuberosities  of  the  ischium,  and  running 
obliquely  forward  and  upward  is  inserted  into  the  lateral  fascia! 
covering  of  the  corpora  cavernosa.  By  their  contraction  they  compress 
the  cavernous  bodies  and  thus  aid  in  erection.  The  bulbocavernosus 
arises  from  the  central  tendon  of  the  perineum,  and  passing  forward 
and  inward  completely  surrounds  the  bulb.  By  its  forcible  contrac- 
tion the  fluid,  urine  and  semen,  which  collects  in  the  bulbous  urethra, 
is  expelled,  thus  assisting  in  the  muscular  effort  concerned  in  ejaculation 
and  in  expelling  the  last  drop  of  urine.  Both  muscles  are  innervated 
by  branches  of  the  internal  pudic  nerve  and  receive  their  blood  supply 
from  the  branches  of  the  internal  pudic  artery. 

Vessels. — The  dorsal  arteries  of  the  penis,  terminal  branches  of  the 
internal  pudics,  pierce  the  suspensory  ligament,  and  running  along  the 
dorsal  surface  beneath  the  fascia  of  the  penis  (Buck's  fascia),  on  either 
side  of  the  deep  dorsal  vein,  terminate  in  anastomosing  branches  about 
the  corona  glandis.  These  two  arteries  supply  the  coverings  of  the 
penis  and  give  off  branches  to  the  corpora  cavernosa.  External  to  the 
dorsal  arteries  and  the  dorsal  nerves  courses  the  external  pudic  branch 
of  the  common  femoral  artery.  This  also  supplies  the  integuments  of 
the  penis.  The  artery  to  the  bulb,  a  branch  of  the  internal  pudic 
artery,  pierces  the  anterior  layer  of  the  triangular  ligament  close  beside 
the  urethra  and  enters  the  bulb.  It  supplies  the  erectile  tissue  of  the 
corpus  spongiosum.  The  artery  of  the  crus,  also  a  branch  of  the 
Internal  pudic,  pierces  the  anterior  layer  of  the  triangular  ligament 
close  to  the  ramus  of  the  pubis  and  enters  the  crus.  They  furnish  the 
main  blood  supply  to  the  corpora  cavernosa.  In  detaching  the  crura 
from  the  bone  in  the  operation  for  the  complete  removal  of  the  penis, 
the  close  proximity  of  these  arteries  to  the  bone  may  give  rise  to  diffi- 
culty in  controlling  hemorrhage.  It  will  be  noted  that  the  arteries 
of  the  penis  supplying  the  erectile  tissue  and  the  envelopes  are  all 
branches  of  the  internal  pudic,  except  the  small  external  pudic  branches 
of  the  common  iliac,  which  supply  blood  to  the  envelopes  only. 

Veins. — The  veins  of  the  penis  are  divided  into  a  superficial  and  a 
deep  venous  network.  The  superficial  veins  situated  in  the  subcutane- 
ous tissue  and  collecting  the  blood  from  the  integument  unite  to  form 
the  superficial  dorsal  vein  of  the  penis.  This  passes  back  to  the  root 


198     ANATOMY,    ANOMALIES  AND  INJURIES  OF   THE   I'ENIS 

of  the  penis,  anastomoses  with  the  venous  network  of  the  abdominal 
wall  and  empties  into  the  saphenous  vein.  The  deep  veins  comprising 
the  branches  from  the  erectile  tissue,  and  situated  beneath  the  fascia 
of  the  penis,  unite  to  form  the  deep  dorsal  vein  of  the  penis.  This 
vein  forms  the  main  venous  trunk  of  the  penis  and,  passing  back, 
between  the  two  layers  of  the  triangular  ligament,  bifurcates  and 
empties  into  the  prostaticovesical  plexus  or  plexus  of  Santorini. 

Lymphatics. — The  lymphatics  of  the  penis,  like  the  veins,  are 
divided  into  a  superficial  and  a  deep  network.  The  superficial  system 
drains  the  prepuce,  skin  and  subcutaneous  tissue.  Some  unite  to 
form  a  common  trunk,  the  superficial  dorsal  lymphatic  trunk,  *which 
empties  into  the  superficial  inguinal  glands.  Others  maintain  their 
independence  and  empty  separately  into  the  inguinal  glands.  The  deep 
lymphatics,  like  the  deep  veins,  lie  beneath  the  fascia  of  the  penis. 
They  drain  the  glans  penis  and  communicate  freely  with  the  lymphatics 
of  the  prepuce  and  the  urethra.  Running  along  the  groove  of  the 
dorsum  of  the  penis  as  a  single  or  as  multiple  (2  to  4)  trunks,  they  form 
a  plexiform  network  in  front  of  the  symphysis,  at  which  level  one  some- 
times encounters  two  or  more  small  glands.  According  to  Cuneo  and 
Marcille  the  deep  lymphatics  empty  for  the  most  part  into  the  deep 
lymphatic  glands  along  the  femoral  and  iliac  arteries  and  only  excep- 
tionally into  the  superficial  inguinal  glands.  This  course  and  termina- 
tion of  the  lymphatics  is  important  to  bear  in  mind  in  the  operation  for 
carcinoma  of  the  penis,  which  disease  practically  always  involves  the 
glans  first.  It  is  necessary  not  only  to  remove  the  superficial  inguinal 
glands  on  both  sides  along  with  the  nodes  in  front  of  the  symphysis, 
but  also  the  deep  glands  along  the  femoral  vein,  under  Poupart's 
ligament  and  the  retro-iliac  glands. 

Nerves. — The  nerve  supply  of  the  penis  is  extremely  rich,  receiving 
filaments  from  both  the  cerebrospinal  and  the  sympathetic  systems, 
the  former  supplying  the  integument  while  the  latter  pass  to  the 
erectile  bodies.  The  glans  is  particularly  rich  in  nerves  which  termi- 
nate in  free  extremities  and  in  special  nerve  endings,  the  genital  nerve 
corpuscles  of  Krause.  The  erectile  bodies  receive  filaments  from  the 
hypogastric  plexus  through  the  nervi  erigentes  which  accompany  the 
arteries  to  the  cavernous  and  spongy  bodies. 

CONGENITAL  MALFORMATIONS. 

Congenital  malformations  of  the  penis,  as  a  whole,  are  extremely 
rare.  They  have  little  clinical  interest  and  are  referred  to  merely  as 
curious  errors  of  development.  They  are  usually  associated  with 
developmental  defects  of  other  organs,  as  the  bladder,  kidneys,  ureters, 
and  rectum.  Congenital  deformities  of  one  or  more  of  the  constituent 
parts  of  the  penis  are,  on  the  contrary,  relatively  common,  and  certain  of 
these  represent  well-known  types;  for  example,  hypospadias,  congenital 
phimosis.  The  penis  may  be  double,  absent,  concealed,  twisted, 
adherent,  or  cleft. 


CONGENITAL  MALFORMATIONS 


199 


Double  Penis. — Double  penis,  penis  duplex,  diphallus  verus,  is 
an  extremely  rare  anomaly  but  by  no  means  as  rare  as  generally  sup- 
posed. Lebrun16  recently  collected  13  cases  of  double  penis  with  double 
urethra  and  omitted  4.  About  double  that  number,  including  all  cases 
of  this  anomaly,  have  been  recorded.  Several  varieties  have  been 
described:  supernumerary  glans,  3  cases;  double  glans  with  a  single 
shaft,  diphallus  partialis,  3  cases;  and  two  separate  well-developed 
penes.  These  are  either  superimposed,  placed  side  by  side,  or  separated 
for  a  greater  or  less  distance.  The  two  urethras  are  separate  and  dis- 
tinct, communicating  with  a  common  bladder,  or  they  unite  in  the 
prostatic  region  (Kiittner's  case15).  In  4  cases  the  bladder  was  double, 


FIG.  113. — Velpeau  and  Gorre's  case. 

and  each  urethra  opened  separately  into  the  bladder  of  the  correspond- 
ing side.  In  the  frequently  quoted  case  of  Alan  P.  Smith29  a  stone 
formed  in  one  of  the  bladders  and  was  successfully  removed.  This 
man  could  void  from  either  bladder  at  will.  One  of  the  most  remark- 
able and  widely  known  cases  occurred  in  the  person  of  Jean  Battista 
dos  Santos,  a  native  of  Faro,  Portugal.  He  was  exhibited  at  several 
European  clinics,  where  a  minute  examination  and  accurate  description 
of  the  malformation  was  made.  In  addition  to  two  well-developed 
penes  he  presented  a  deformed  supernumerary  lower  extremity  pro- 
jecting between  the  normal  thighs.  A  wax  model  of  the  penile  malfor- 
mation is  in  the  Army  Medical  Museum  at  Washington.  (A  descrip- 
tion of  this  interesting  case  together  with  photographs  by  Mr.  Hart 


200    ANATOMY,   ANOMALIES  AND  INJURIES  OF  THE  PENIS 

will  be  found  in  Lancet,  London,  1865,  ii,  124.)  Curious  variations 
in  the  functions  of  the  two  organs  have  been  observed.  In  13  cases 
urine  was  voided  by  both  urethras,  Ollsner's  patient24  voided  through 
the  right  and  ejaculated  through  the  left  penis.  Two  patients  (Xie- 
man,22  St.  Hilaire-8)  passed  both  urine  and  semen  by  both  urethras.  In 
2  cases  with  imperforate  anus,  feces  and  urine  escaped  together. 
Keppel14  observed  that  the  right  penis  of  his  patient  was  used  for 
urination  only,  while  the  left  was  the  only  one  capable  of  erection  under 
excitation. 


FIG.  114. — Lange's  case. 

Reduplication  of  the  penis  never  occurs  alone,  but  is  always  associ- 
ated with  other  marks  of  fetal  inclusion.  A  number  of  cases  have  been 
observed  in  children  who  presented  other  abnormalities  incompatible 
with  life,  such  as  imperforate  anus,  and  it  was  for  the  relief  of  this  con- 
dition that  they  came  under  observation.  In  adults  the  condition  is 
nearly  always  discovered  accidentally  during  examination  for  some 
other  unrelated  malady.  It  is  probable,  therefore,  that  this  ab- 
normality is  not  as  rare  as  the  number  of  cases  reported  would  indicate, 
since  these  unfortunates  are  careful  to  guard  their  secrets  and  do  not 
come  under  observation  except  \vhen  compelled  to  by  necessity.  Other 
abnormalities  associated  with  reduplication  of  the  penis  are  double 
bladders,  hernia,  and  exstrophy  of  the  bladder,  cleft  scrotum,  imper- 
forate anus,  and  hypospadias.  Volpe's32  case  is  unique;  this  infant 


CONGENITAL  MALFORMATIONS  201 

with  imperforate  anus  had  a  double  penis,  urethra,  bladder,  and 
scrotum,  with  a  single  (horseshoe)  kidney  and  a  single  ureter  opening 
into  the  left  bladder,  a  fusion  of  the  organs  normally  double  and  a 
reduplication  of  the  organs  normally  single. 

Treatment. — Surgical  intervention,  except  in  rare  cases,  is  limited  to 
the  treatment  of  associated  malformations  requiring  operation.  In  2 
cases  an  operation  was  performed  for  atresia  of  the  anus;  1  (Coles)8 
was  successful.  In  a  favorable  case  an  accessory  penis  can  be  removed, 
as  was  done  by  Lionti17  and  Albrecht,2  with  very  good  chances  for 
excellent  functional  results.  Except  in  these  rare  instances  surgical 
treatment  is  of  no  avail,  and  therefore  not  indicated. 

Absence  of  the  Penis. — Congenital  absence  of  the  penis  is  exceedingly 
rare,  and  unlike  reduplication,  is  not  accompanied  by  other  gross 
malformations  of  the  external  genitals  or  developmental  defects  in  other 
parts  of  the  body.  This  condition  must  not  be  confused  with  con- 
cealed or  apparent  absence  of  the  organ,  or  with  pseudohermaphro- 
ditism.  The  penis  is  completely  wanting,  the  urethra  opens  upon  the 
perineum  or  on  the  anterior  wall  of  the  rectum.  The  subjects  of  this 
deformity  are  in  other  respects  normally  developed  with  well-marked 
secondary,  sexual  characteristics.  The  scrotum  is  normal,  the  testicles 
are  present,  but  not  pendant.  The  extreme  rarity  of  this  anomaly 
is  evident  from  the  fact  that  only  7  cases  have  been  recorded.  Harris11 
collected  5,  added  1  of  his  own  but  omitted  1  (Revolat).  I  have  not  been 
able  to  find  any  others  reported  since.  It  is  curious  that  the  earlier 
literature  contains  no  mention  of  this  anomaly.  There  were  two 
infants,  the  others  wrere  adults,  and  in  three  of  these  the  urethra  opened 
into  the  rectum.  Mathews'sls  patient,  a  man,  aged  thirty  years,  had 
been  married  several  years.  His  secret  was  known  only  to  his  mother 
and  family  physician  previous  to  marriage.  He  died  of  kidney  in- 
fection following  a  simple  operation  for  hemorrhoids.  In  two  adults 
with  the  urethra  opening  into  the  bowel  the  kidney  did  not  become 
infected. 

Concealed  Penis. — In  cases  of  apparent  absence,  the  penis  is 
dwarfed  and  concealed  beneath  the  skin  of  the  scrotum  or  perineum. 
This  condition  is  easily  mistaken  for  that  of  true  congenital  absence. 
Careful  search,  however,  will  reveal  a  rudimentary  organ  concealed 
beneath  the  skin.  Cases  have  been  described  by  Chopert,  Bouteillier, 
and  more  recently  by  Mocquot,  and  Aievoli.1  In  Mocquot's20  case,  a 
man  sixty-one  years  of  age,  the  scrotum  was  normal  and  both  testicles 
present  but  not  pendant.  In  the  normal  position  of  the  penis  there  was 
a  depression  surrounded  by  a  fold  of  skin,  in  the  depth  of  which  a 
cylindrical  body  could  be  felt.  This  was  a  rudimentary  penis,  7  cm. 
long  and  about  the  size  of  one's  little  finger.  In  the  case  recorded  by 
Aievoli  the  penis  was  covered  completely,  even  the  glans,  by  the  skin 
of  the  scrotum. 

Treatment. — The  treatment  consists  in  the  liberation  of  the  penis  by 
incision  and  in  supplying  a  covering  of  integument  from  the  adjacent 
parts  by  an  appropriate  operation. 


202     ANATOMY,  ANOMALIES  AND  INJURIES  OF  THE  PENIS 

In  the  newborn  with  retention  resulting  from  this  deformity,  libera- 
tion of  the  penis  by  dissection  must  be  done  at  once;  the  plastic  opera- 
tion may  be  deferred  until  later,  as  was  done  by  Aievoli. 

Torsion. — Torsion  of  the  penis  or  twisting  in  its  long  axis  may 
occur.  The  frenum  then  comes  to  occupy  a  mid-dorsal  position.  It  is 
usually  associated  with  hypospadias,  epispadias,  or  other  penile  defects. 
Cases  have  been  reported  by  Jacobson.  Very  rarely  this  deformity 
exists  alone  and  independent  of  any  other  deformity,  as  in  Caddy's7 
case. 

Adherent  Penis. — Adhesions  between  the  penis  and  scrotum 
together  with  marked  incurvation  occur  as  a  complication  of  scrotal 
hypospadias.  Freeing  of  these  fibrous  attachments  and  straightening 
the  penis  constitutes  the  first  step  in  any  operation  for  hypospadias. 
In  the  absence  of  any  urethral  defect  the  penis  may  be  enclosed  by  the 
scrotal  integument  throughout  its  entire  length.  Such  a  case  of  webbed 
penis  is  described  by  Mummery.21  More  commonly  the  attachment  of 
the  scrotum  extends  forward  along  the  under  surface  of  the  penis  a 
varying  distance,  and  may  seriously  interfere  with  coitus  (Verge 
palme).  The  treatment  is  simple,  and  consists  in  severing  the  attach- 
ments as  far  as  necessary  and  suturing  the  loose  skin  in  the  corrected 
position. 

Cleft  Penis. — There  is  only  one  case  of  transverse  cleft  or  splitting 
of  the  glans  on  record.  This  singular  abnormality  is  described  by 
Hofmokl12  in  a  man,  aged  sixty-eight  years,  with  congenital  phimosis. 
Retracting  the  prepuce  it  was  discovered  that  the  glans  was  divided  by 
a  deep  transverse  cleft  into  a  thickened  dorsal  and  a  thinner  ventral 
portion.  The  urethra  opened  in  the  midline  at  the  bottom  of  the 
deep  sulcus.  There  was  a  shallow,  blind  opening  on  the  inner  surface 
of  the  lower  segment.  This  man  had  been  married  twice  and  was  the 
father  of  eight  children. 

A  vertical  cleavage  of  the  glans  would  appear  to  be  more  common, 
but  nevertheless  extremely  rare.  When  complete,  a  double  glans  results 
(see  above).  Trenkler30  has  recently  observed  a  remarkable  case  of 
cleft  penis  in  a  strong,  healthy  young  man  without  any  other  congenital 
defect.  The  appearance  was  that  of  a  double  penis  in  which  the  left 
one  was  rotated  slightly  under  the  other.  Examination  showed  that 
in  reality  the  condition  was  not  that  of  duplication,  but  that  a  vertical 
cleft  involving  the  corpora  cavernosa  and  the  urethra  separated  the 
two  bodies  completely.  By  drawing  the  two  halves  wide  apart  the 
urethral  opening  could  be  seen  at  the  bottom  of  the  sulcus.  On  the 
inner  aspect  of  either  half,  extending  from  the  urethral  opening  to 
the  tip,  was  a  narrow  band  of  mucous  membrane.  These  presented 
numerous  pits  or  lacunae,  and  represented  the  lateral  walls  of  the  cleft 
urethra. 

Hypospadias  and  Epispadias. — Hypospadias  is  a  congenital  defect 
of  the  anterior  urethra,  the  canal  terminating  at  some  point  behind  the 
normal  position  of  the  meatus.  This  defect  varies  in  degree  from  a 
mere  elongation  of  the  meatus  to  a  complete  absence  of  the  urethra  in 


CONGENITAL  MALFORMATIONS  203 

front  of  the  perineum.  It  never  extends  beyond  this  point,  hence  the 
posterior  urethra  escapes,  the  sphincters  are  competent,  and  the 
patient  is  always  able  to  control  his  urine.  Eleven  varieties  of  hypo- 
spadias  have  been  described,  but  for  practical  purposes  it  is  necessary  to 
distinguish  only  three,  which  are,  in  the  order  of  their  frequency  of 
occurrence,  balanitic  (glandular) ,  penile,  and  perineal  (perineoscrotal) . 
In  balanitic  hypospadias  the  urethra  opens  just  behind  the  glans  at  a 
point  where  the  frenum,  which  is  absent,  is  normally  attached.  The 
glandular  urethra  is  either  entirely  wanting,  or  there  may  be  a  shallow 
groove,  or  a  deep  furrow,  lined  by  mucous  membrane  which  represents 
the  roof  of  the  fossa  navicularis.  The  glans  is  generally  broader  than 
normal,  somewhat  flattened,  and  slightly  incurved.  The  malformed 
prepuce  forms  a  redundant  hood-like  fold  on  the  dorsal  aspect  of  the 
glans.  This  degree  of  hypospadias  causes  little  inconvenience  or  inter- 
ference with  function  and  therefore  seldom  requires  treatment  other 
than  the  occasional  dilatation  of  a  contracted  urethra!  opening. 

In  penile  hypospadias  the  deformity  is  much  greater.  The  urethral 
opening  may  be  situated  at  any  point  along  the  floor  of  the  penile  ure- 
thra, but  is  usually  just  behind  the  glans,  midway  between  the  glans  and 
scrotum,  or  at  the  penoscrotal  juncture.  Associated  deformities  are 
much  more  common  in  this  variety  and  usually  are  more  marked  the 
greater  the  degree  of  hypospadias.  When  the  hypospadiac  opening  is 
in  the  anterior  portion  of  the  penile  urethra  the  penis  may  be  well 
formed  and  its  functions  quite  normal,  but  in  penoscrotal  hypospadias 
the  member  is  usually  small,  malformed,  and  markedly  incurved  upon 
the  scrotum  to  which  it  may  be  partially  adherent.  The  corpora 
cavernosa  are  poorly  developed.  The  urethra  in  front  of  the  abnormal 
opening  is  most  often  obliterated  and  when  an  attempt  is  made  to 
straighten  the  penis  this  stands  out  as  a  tense  fibrous  cord.  Excep- 
tionally it  may  remain  patulous  up  to  the  meatus,  end  in  a  cul-de-sac, 
or  in  a  secondary  fistulous  opening. 

Perineal  hypospadias  represents  the  extreme  grade  of  the  deformity 
and  is  fortunately  very  rare.  The  associated  malformation  of  the 
external  genitals  is  most  marked.  The  scrotum  is  divided  by  a  deep 
cleft,  each  half  containing  a  normal  testicle,  more  often  an  atrophied 
testicle,  or,  when  these  have  been  retained,  none  at  all.  In  any  case 
the  cleft  scrotum  closely  resembles  the  vulva,  the  two  halves  represent- 
ing the  labia  majora.  The  penis  is  dwarfed  and  may  be  completely 
concealed,  except  for  the  glans,  by  a  redundant  fold  of  scrotal  tissue,  and 
is  easily  mistaken  for  an  hypertrophied  clitoris.  The  urethral  opening 
forms  a  funnel-shaped  depression  lined  by  mucous  membrane  and  con- 
cealed under  the  retracted  and  incurved  penis.  Occasionally  the  ure- 
thra may  continue  forward  to  its  tip  as  a  groove  on  the  under  surface 
of  the  stunted  penis.  In  a  pronounced  case  it  may  be  very  difficult 
to  determine  the  sex  of  the  individual.  The  functions  of  the  penis  are 
little  disturbed  in  balanitic  hypospadias.  The  stream  of  urine  may  be 
very  small  on  account  of  the  contracted  opening,  or  scattered  and 
directed  to  one  side  or  downward  as  a  result  of  the  associated  penile 


2i>4     ANATOMY,    AXOMALIES   AXD   I.\J CRIES   OF    THE    I'EXIS 

deformity.  In  the  penoscrotal  and  perineal  variety,  function  is  mark- 
edly interfered  with.  Coitus  is  difficult  or  impossible,  and  sterility  is 
the  rule.  In  urinating,  the  patient  must  sit  down  to  avoid  wetting  his 
clothes;  the  urine  bathes  the  adjacent  parts  which  become  excoriated 
and  eczematous. 

Etiology. — Hypospadias  is  manifestly  a  congenital  defect  and  is  due 
to  an  error  in  development.  The  posterior,  penile,  and  glandular 
urethra  develop  separately.  At  one  stage  in  its  development  the 
urethra  is  an  open  gutter  or  groove,  the  sides  of  which  unite  in  the 
median  line  to  form  the  floor  of  the  canal.  If  for  any  reason  the  process 
is  arrested  at  any  point,  or  the  separate  portions  fail  to  unite  properly, 
closure  is  incomplete  and  hypospadias  results.  The  causes  underlying 
the  arrest  of  development  are  not  well  understood.  The  condition  is 
unquestionably  hereditary.  Kaufmann13  has  proposed  an  ingenious 
theory  to  explain  hypospadias  and  its  accompanying  deformities.  He 
assumes  that  there  is  a  failure  of  the  separate  portions  to  unite  properly 
which  results  in  atresia  of  the  urethra.  When  the  kidneys  begin  to 
secrete,  the  urine  ruptures  the  urethral  floor  behind  the  point  of 
occlusion  and  hypospadias  results. 

Treatment. — In  the  treatment  of  hypospadias  one  aims  to  correct 
deformities  and  restore  normal  function.  Whether  an  operation  should 
be  advised  or  not  depends  upon  whether  the  degree  of  deformity  and 
the  resulting  disturbance  of  functions  are  sufficient  to  demand  surgical 
relief.  In  balanitic  hypospadias  operation  is  rarely,  if  ever,  indicated. 
The  deformity  is  so  slight  that  the  disturbance  in  function  is  trivial 
and  does  not  justify  any  surgical  operation.  Two  operative  pro- 
cedures have  been  described,  those  of  Duplay  and  of  Beck. 

Dnplay's  Operation  for  Glandular  Hypospadias. — This  operation  is 
well  adapted  to  cases  in  which  there  is  a  groove  on  the  under  surface  of 
the  glans  representing  the  glandular  urethra.  The  edges  of  this  groove 
are  freshened  and  brought  together  in  the  midline  over  a  retention 
catheter  by  interrupted  sutures  of  fine  silk  or  chromic  catgut.  When 
the  flaps  are  too  short  to  come  together  without  undue  tension,  lateral 
incisions  into  the  glandular  tissue  are  made  which  will  overcome  this 
difficulty.  The  retention  catheter  is  retained  until  complete  healing 
takes  place. 

Beck's  Operation.4 — This  procedure  is  said  to  be  suitable  for  cases 
in  which  the  hypospadiac  opening  is  just  at  the  margin  of  or  just  behind 
the  glans  and  the  latter  is  not  grooved  on  its  under  surface.  A  circular 
incision  is  made  about  the  hypospadiac  opening  and  this  is  extended 
laterally  on  either  side  along  the  sulcus  behind  the  corona.  A  longi- 
tudinal incision  is  then  made,  beginning  at  the  hypospadiac  orifice  and 
extending  along  the  line  of  the  urethra.  The  two  skin  flaps  thus 
marked  out  are  dissected  up.  The  urethra  is  then  mobilized  by  dissect- 
ing the  spongy  body  free  from  its  bed  for  a  certain  distance.  The 
glans  is  now  tunnelled  by  passing  a  long  narrow-blade  scalpel  from  be- 
hind forward  through  the  glans,  emerging  at  its  summit.  This  tunnel 
must  be  enlarged  by  dilatation  or  crucial  incision.  A  pair  of  Kocher 


CONGENITAL  MALFORMATIONS  205 

forceps  are  now  passed  through  this  new  meatus,  the  end  of  the  liber- 
ated urethra  seized  and  drawn  through  the  tunnel.  The  dislocated 
urethra  is  sutured  in  place  by  interrupted  sutures  passing  through  the 
edge  of  the  urethra  and  glans.  The  operation  is  completed  by  approxi- 
mating the  skin  flaps  to  cover  the  raw  surface.  The  distance  the  ure- 
thra is  dissected  free  depends  upon  the  amount  of  forward  dislocation 
necessary.  The  urethra  should  not  be  under  any  considerable  amount 
of  tension  when  sutured  in  its  new  position,  otherwise  retraction  will 
occur  and  the  result  will  be  a  failure  either  from  the  sutures  giving  way 
or  from  a  pronounced  incurvation  of  the  penis.  Indeed,  the  tendency 
toward  the  latter  deformity  seems  to  be  one  of  the  chief  objections  to  an 
otherwise  theoretically  ideal  operation.  The  technic  is  slightly  modi- 
fied when  the  glans  is  grooved  as  shown  in  Figs.  115,  116,  117  and  118. 
My  personal  experience  with  Beck's  operation  in  a  small  number  of 
cases  has  been  100  per  cent,  failure,  due  to  recontraction  of  the  dis- 
located urethra  and  incurvation  of  the.  glans.  A.  C.  Wood,  of  Phila- 
delphia, has  reported  a  similar  experience.  I  am  of  the  opinion  that 
the  procedure  of  Beck  is  faultily  conceived  for  the  repair  of  a  defect 
which  should  rarely,  if  ever,  be  subjected  to  surgical  attack.  This 
operation  as  well  as  the  preceding  one  can  be  carried  out  in  one  stage. 

In  penoscrotal  and  perineal  hypospadias  an  operation  is  always 
indicated  and  its  object  is  twofold :  to  straighten  the  penis  and  recon- 
struct the  urethra.  A  number  of  operations  have  been  described  and 
performed  which  differ  in  the  ingenious  methods  advised  for  the  repair 
of  urethral  defects.  The  different  procedures  are  all  modifications  of 
two  fundamentally  different  methods,  namely,  urethroplasty  by  tun- 
nelling, and  by  the  use  of  flaps.  The  operations  of  No  ve- Josser  and, 
Rochet,  and  Mayo  are  examples  of  the  first.  While  those  of  Duplay 
and  Beck  represent  the  second  method. 

The  first  step  in  all  operations,  and  common  to  all,  is  to  straighten 
the  penis.  A  transverse  incision  is  made  through  the  fibrous  band 
which  holds  the  penis  retracted  and  incurved  on  the  scrotum.  At  times 
multiple  incisions  must  be  made  to  completely  free  the  penis.  It  may 
be  necessary  to  carry  this  incision  into  the  sheath  of  the  cavernous 
bodies,  care  being  taken  not  to  injure  the  latter,  and  if  the  spongy  body 
is  too  short  and  interferes  with  complete  liberation  of  the  penis,  it 
should  be  dissected  up  and  allowed  to  retract.  All  constrictions  having 
been  divided,  the  penis  is  fully  extended  and  the  incision  closed  by  trans- 
versely placed  interrupted  sutures.  It  is  maintained  in  an  extended 
position  by  appropriate  dressings  until  healing  is  complete.  At  the 
time  of  the  straightening  of  the  penis  Pousson  advises  straightening  the 
glans  by  his  technic  of  "  redressement."  A  transverse  V-shaped  wedge 
of  tissue  is  removed  from  the  dorsal  surface  just  behind  the  glans. 
When  the  edges  of  the  wound  are  sutured,  the  incurvation  of  the  glans 
is  overcome. 

One  should  wait  from  four  to  six  months  after  the  first  stage  before 
beginning  the  plastic  repair  of  the  urethra  in  order  to  be  sure  no  further 
retraction  will  occur  and  to  allow  the  scar  tissue  to  become  freely  movable. 


206     AX  ATOMY,   AXOMALIES  AXD  IX  JURIES  OF   THE   PEXIX 


FIG.  115. — Beck's   operation  for  hypo- 
spadias.      (Watson  and  Cunningham.) 


FIG. 


116. — Beck's  operation, 
and  Cunningham.) 


(Watson 


FIG.   117. — Beck's   operation, 
and  Cunningham.) 


(Watson 


FIG.  118. — Beck's  operation.     (Watson 
and  Cunningham.) 


CONGENITAL  MALFORMATIONS 


207 


DupJay's  Operation  (Pousson's  technic26). — In  this  operation  the 
urethral  defect  is  repaired  by  flaps  taken  from  the  penis  itself.  This 
operation  or  a  slight  modification  is  the  one  most  generally  used. 

First  Stage. — Begins  by  straightening  the  penis  as  already  described. 

Second  Stage. — A  preliminary  perineal  section  is  done  to  divert  the 
urine  through  a  perineal  fistula.  This  is  absolutely  essential  to  the 
success  of  any  operation  for  hypospadias.  An  incision  is  then  made  on 
the  under  surface  of  the  penis  parallel  to  its  long  axis  about  8  mm.  from 
the  midline  and  extending  from  the  summit  of  the  glans  to  the  level  of 
the  hypospadiac  orifice.  At  each  extremity  of  this  incision,  incisions 
AC  and  BD  are  made  at  right  angles  extending  outward  a  distance  of 
6  mm.  The  flap  E  thus  outlined  is  then  dissected  up  toward  the  out- 
side. Shorter  incisions  (AF,  EG]  mark  out  a  narrower,  inner  flap  ( //). 


FIG.  119  FIG.  120 

FIGS.  119  and  120. — Duplay's  operation  for  penoscrotal  hypospadias. 

(Pousson's  technic.) 


Similar  flaps  are  made  on  the  opposite  side  of  the  midline,  an  outer  and 
an  inner,  with  this  difference,  that  the  longitudinal  incision  is  only 
5  mm.  from  the  midline  and  the  inner  flap  ( 77')  is  therefore  narrower. 
The  two  flaps  (//  and  //')  are  sutured  together  over  a  catheter  and  form 
an  inner  layer  on  the  floor  of  the  new  urethra.  As  these  two  flaps  are  of 
an  unequal  width,  the  suture  line  will  be  at  one  side  and  therefore  not 
directly  under  the  outer  suture  line.  Flaps  E  and  Ef  are  then  brought 
together  to  cover  in  the  raw  surface  and  form  the  outer  layer  of  the 
double  urethral  floor. 

Third  Stage. — Closure  of  the  Perineal  Fistula. — Drainage  of  the  blad- 
der through  the  perineal  opening  should  be  maintained  until  complete 
healing  has  taken  place  and  one  is  sure  that  displacement  of  the  flaps 
due  to  faulty  suturing  or  infection  will  not  result  in  the  formation  of  a 
fistula.  The  perineal  fistula  is  then  closed  in  the  usual  way. 


208     ANATOMY,   AXOMALIES   AXD  IXJl'lUKH  OF   THE  PENIS 

Beck's  Operation. — This  operation  makes  use  of  flaps  derived  from  the 
penis  and  scrotum.  On  either  side  of  the  midurethral  line  and  several 
millimeters  distant  a  longitudinal  incision  is  made  extending  from  the 
summit  of  the  glans  to  just  beyond  the  level  of  the  abnormal  urethral 
opening.  These  are  joined  by  transverse  incisions  at  either  extremity. 


FIG.  121. — Beck's  operation  for  scrotal  hypospadias. 

Cunningham.) 


First  step.     (Watson  and 


The  flap  thus  outlined  is  dissected  up  on  either  side  and  the  edges 
brought  together  over  a  catheter  in  the  midline  by  interrupted  sutures, 
thus  forming  a  urethra  with  an  epidermal  lining.  A  flap  is  now  marked 
out  on  the  scrotum  with  its  base  at  the  abnormal  urethral  opening  of 
proper  shape  and  size  to  cover  in  the  raw  surface  left  by  the  first  flap. 


CONGENITAL  MALFORMATIONS 


209 


This  is  rotated  on  its  base  and  sutured  in  place  over  the  new  urethra. 
The  scrotal  wound  is  closed  by  direct  suture  (Figs.  121,  122  and  123). 
Nove-Josserand's  Operation.23 — This  is  the  best-known  procedure 
in  which  urethroplasty  is  made  by  tunnelling  and  the  use  of  grafts.  The 
results  obtained  by  the  technic  originally  described  were  unsatisfactory, 


^^^^^^ 

Fiu.   122. Beck's  operation  for  scrotal  hypospadias.     Second  step.      (Watson  and 

Cunningham.) 

as  a  fistula  at  the  juncture  of  the  new-formed  and  normal  urethra  was 
practically  constant,  and  the  new  canal  showed  a  marked  tendency  to 
contract.  This  technic  was  subsequently  modified  and  the  results 
obtained  by  the  originator  of  the  operation  have  been  recently  fully 
analyzed. 

M  U       1—14 


210     ANATOMY,  ANOMALIES  AND  INJURIES  OF   THE  PENIS 

Step  One. — The  urine  is  diverted  by  a  perineal  urethrostomy,  the 
edges  of  the  urethra  being  sutured  to  the  skin.  Redressement  of  the 
penis  is  then  made.  At  the  same  time  the  hypospadiac  urethral  open- 
ing is  excised  together  with  2  or  3  cm.  of  the  urethra,  a  ligature  placed 


FIG.  123. — Beck's  operation  for  scrota!  hypospadias. 

Cunningham.) 


Third  step.     (Watson  and 


about  the  stump  and  the  wound  in  the  penile  urethra  sutured  (Figs. 
124  and  125).  The  penis  is  immobilized  against  the  abdominal  wall 
by  appropriate  dressings  and  one  waits  for  two  or  three  months. 

Second  Step. — This  consists  in  tunnelling  the  new  urethra  and  apply- 
ing the  graft.     A  trocar  is  introduced  through  the  urethrotomy  wound, 


CONGENITAL  MALFORMATIONS 


211 


directed  along  the  course  of  the  proposed  new  urethra  and  brought  out 
at  the  position  of  the  new  meatus.  This  tunnel  is  enlarged  by  special 
instruments.  A  dermo-epidermal  graft  is  taken  from  the  inside  of  the 
thigh,  an  area  free  from  hair,  this  is  wound  spirally  around  a  staff  and 
fastened  at  either  end  by  catgut  ligatures.  The  staff  carrying  the  graft 
is  now  introduced  into  the  tunnel  from  behind  forward  and  fastened 
into  position  (Figs.  126, 127  and  128).  At  the  end  of  about  eight  days 
the  staff  is  removed  and  after  an  interval  of  about  three  or  four  weeks 
bougies  are  passed  to  dilate  the  channel.  It  has  been  found  that 
contraction  will  occur,  and  to  overcome  this  an  internal  urethrotomy 


FIG.   124.  —  Nove-Josserand  operation  FIG.   125.  —  Nov6-Josserand  operation 

for  perinoal   hypospadias.     Formation  of  for     perineal     hypospadias.      Excision   of 

porincal   fistula.     Incision   around   hypo-  hypospadiac  opening.     Sutures  in  place, 
spadiac  opening. 

is  done  after  two  or  three  months,  just  as  is  done  for  a  stricture  in  an 
otherwise  normal  urethra. 

Third  Step. — This  comprises  the  closure  of  the  perineal  fistula  by 
the  usual  technic.  The  operation  of  Xove-Josserand  is  suitable  for 
perineal  hypospadias  as  well  as  penile. 

Rochefs  Operation. — Rochet31  has  proposed  the  transplanting  of  a 
skin  flap  taken  from  the  scrotum  in  place  of  the  graft  used  by  Nove- 
Josserand,  while  Mayo  and  Donnet9  each  have  described  a  technic  of 
transplanting  a  flap  taken  from  the  redundant  prepuce  in  cases  of 
penile  hypospadias. 


212     ANATOMY,  ANOMALIES  AND  INJURIES  OF   THE  PENIS 

In  the  plastic  repair  of  urethral  defects  the  transplantation  of  a 
section  of  vein  or  ureter  has  been  suggested.  Tanton  has  successfully 
experimented  on  dogs  and  more  recently  operated  on  a  patient,  using 
the  saphenous  vein  for  the  transplantation.  This  procedure  has  also 
been  used  by  Tuffier,  Potel  and  Leriche,  Becker,  Stettiner  and 
Schmieden.  It  is  probable  that  this  method  of  urethroplasty  event- 
ually will  come  into  more  general  use.  It  must  be  said,  however, 


FIG.  126.  —  Nove-Josserand  operation  for 
perineal  hypospadias.  Hypospadiac  opening 
closed.  Formation  of  new  urethra  by  tunnelling 
with  a  special  instrument. 


FIG.  127. — Nove-Josserand  opera- 
tion for  perineal  hypospadias.  Prep- 
aration of  graft.  This  is  wound  spi- 
rally around  a  catheter  and  anchored 
at  either  end  by  ligatures. 


that  any  operation  for  hypospadias  is  difficult,  due  chiefly  to 
the  failure  to  get  primary  union.  A  fistula  often  results  from 
infection  and  breaking  down  of  the  wound,  which  may  require 
a  long  time  and  repeated  efforts  to  close.  Great  care  and  gentle- 
ness in  handling  the  tissues  is  necessary  for  success.  Preliminary 
perineal  drainage  is  indispensable.  At  what  age  should  operation  for 
hypospadias  be  undertaken  ?  In  cases  of  marked  deformity  this  should 
be  corrected  early,  otherwise  development  will  be  seriously  interfered 


213 


with.  About  the  sixth  year  is  the  most  suitable  time  for  the  first  step. 
It  is  better,  according  to  Albarran,  to  wait  several  years,  until  the  parts 
are  fully  developed  before  attempting  the  plastic  repair  of  the  urethra, 
about  the  sixteenth  to  eighteenth  year.  According  to  the  experience 
of  some  other  surgeons,  better  results  are  obtained  when  the  operation 
is  completed  before  puberty. 

Epispadias. — In  this  deformity  the  urethra  lies  above  the  corpora 
cavernosa  in  the  mid-dorsal  line  and  the  roof  of  the  canal  is  partly  or 
wholly  absent.  It  is  relatively 
rare.  In  the  department  of 
the  Seine  one  case  of  epis- 
padias  was  found  in  6000 
recruits,  while  Marshall  did 
not  find  a  case  in  examining 
60,000  conscripts.  Baron 
observed  300  cases  of  hypo- 
spadias  for  two  of  epispadias. 
Three  degrees  of  epispadias 
occur:  balinitic,  penile  and 
complete,  or  penopubic.  In 
the  balinitic  form  the  urethra 
opens  upon  the  upper  surface 
of  the  glans  or  at  the  level  of 
the  coronary  sulcus,  the  glan- 
dular urethra  being  repre- 
sented by  a  groove.  In  penile 
epispadias,  which  is  very  rare, 
the  urethra  opens  farther 
back  on  the  upper  surface  of 
the  penis  and  extends  forward 
as  a  groove  to  the  tip  of  the 
glans.  Complete  epispadias 
is  characterized  by  complete 
absence  of  the  roof  of  the 
urethra  and  is  nearly  always 
associated  with  exstrophy  of 
the  bladder  and  separation 
of  the  pubic  bones.  In  these 
cases  the  penis  is  deformed; 
it  is  short,  broad,  and  gen- 
erally curved  upward  against  the  pubes.  The  urethral  opening  is 
large,  infundibuliform,  often  admitting  the  examining  finger.  It  is 
usually  concealed  by  an  overhanging  fold  of  pubic  tissue  above,  and 
below  by  the  penis,  which  is  strongly  curved  upward  against  the  open- 
ing. The  prepuce  is  divided  and  is  redundant  on  the  under  surface 
of  the  glans.  In  balanitic  epispadias  the  functional  disturbances  are 
less  marked.  Coitus  is  usually  difficult  on  account  of  the  brevity  of 
the  penis,  and  the  stream  of  urine  is  spattering.  In  the  more  marked 


FIG.  128.  —  Nove-Josserand  operation  for 
perineal  hypospadias.  Introduction  of  graft 
into  the  newly  formed  canal,  made  by  transfixing 
the  tissues. 


214     ANATOMY,   ANOMALIES   AND   INJURIES  OF    THE   PENIS 

cases  the  associated  penile  deformity  makes  coitus  impossible,  while 
the  constant  dribbling  of  incontinence  renders  the  condition  of  these 
unfortunates  well-nigh  intolerable.  Incontinence  of  urine,  absent  in 
some  cases  of  most  marked  epispadias,  is  partial  or  intermittent  in 
others,  and  is  always  absolute  when  the  posterior  urethra  is  involved. 
In  the  latter  case  there  is  usually  a  separation  of  the  pubic  bones  and 
exstrophy  of  the  bladder,  or  hernia  without  exstrophy. 

Etiology. — This  condition  is  obviously  due  to  arrested  development 
whereby  complete  closure  of  the  canal  does  not  take  place.  Xo  satis- 
factory explanation,  however,  has  yet  been  offered  as  to  how  or  why  the 
urethra  comes  to  lie  above  the  corpora  cavernosa.  The  very  rare  cases 
of  complete  separation  of  the  cavernous  bodies  with  the  urethral  open- 
ing situated  in  the  angle  between  them  really  represents  an  intermediate 
stage  in  the  migration  of  the  urethra  from  its  normal  position  to  that 
occupied  in  epispadias. 

Treatment. — The  treatment  is  either  palliative  or  radical.  Palliative 
treatment  consists  in  devising  some  sort  of  apparatus,  which  the  patient 
wears  constantly,  for  collecting  the  urine.  The  irritation  of  the  urine 
continually  bathing  the  parts,  the  odor,  and  the  leakage  makes  this  form 
of  treatment  unsatisfactory  and  insupportable.  The  surgical  treat- 
ment of  epispadias  is  difficult,  tedious,  and  requires  time,  patience, 
and  skill.  Several  successive  operations,  separated  by  a  considerable 
interval  of  time  are  required,  and  a  successful  result  is  often  delayed  by 
the  formation  of  fistulse  which  are  difficult  to  heal.  As  in  the  treat- 
ment of  hypospadias,  the  preliminary  step  in  any  operative  procedure 
consists  in  establishing  drainage  through  a  perineal  fistula  and  the 
redressement  of  the  penis.  Having  secured  perineal  drainage  through 
a  perineal  fistula,  time  should  be  allowed  for  complete  healing  of  the 
eczematous  condition  usually  present,  before  attempting  to  straighten 
the  penis.  This  latter  is  accomplished  by  severing  all  constricting 
bands  and  bandaging  the  penis  to  a  splint  in  the  extended  position. 
Several  methods  have  been  described  for  the  repair  of  this  urethral 
defect.  The  procedure  of  Duplay  is  the  simplest.  The  edges  of  the 
urethral  canal  are  freshened  and  brought  together  by  suture  over  a 
sound.  This  simple  urethrorraphy  is  suitable  for  those  cases  only  where 
the  urethral  groove  is  deep  and  the  edges  can  be  approximated  without 
undue  tension. 

In  Thiersch's  operation  the  new  urethra  is  constructed  of  flaps  taken 
from  the  penis,  prepuce,  and  pubic  region. 

First  Step. — The  penile  urethra  is  formed  of  flaps  taken  from  the 
penis  itself.  The  method  has  been  already  described  under  Duplay's 
operation  for  penile  hypospadias,  which  was  adapted  from  Thiersch's 
operation. 

Second  Step. — After  several  weeks  or  months  one  proceeds  to  recon- 
struct the  glandular  urethra.  This  is  done  by  freshening  the  edges  of 
the  glandular  urethra  and  suturing  over  a  sound. 

Third  Step. — This  consists  in  the  repair  of  the  deformed  prepuce. 
A  transverse  incision  is  made  at  the  base  of  the  prepuce,  and  through  this 


CONGENITAL  MALFORMATIONS 


215 


FIG.  129. — Thiersch  operation  for  epi- 
spadias.  Dissection  of  flaps  and  first  row 
of  sutures. 


FIG.  130. — Thiersch  operation  for  epi- 
spadias.  Flaps  sutured  in  place,  incision 
of  prepuce. 


Fro.  131. —Thiersch  operation  for  epispadias.  Prepuce  drawn  over  the  glans  and 
sutured  in  place.  A  flap  from  the  pubic  region  covers  the  pubic  opening  of  the  newly 
formed  canal  and  the  raw  surface  id  covered  by  suturing. 


AA 


THE 


opening  the  glans  i<  drawn.  The  c'ntV  of  prepuee.  thus  transferred  to 
the  dorsum  of  the  dans,  is  sutured  in  this  position  to  a  freshened  area 
and  serv<  -  or  any  fistula  remaining  between  the  balanitie  and 

penile  urethra. 

Fourth  Step.  —  The  epispadiae  opening  remains  to  be  closed  by  flaps 

taken  from  the  pubis.     The  method  of  employing  these  flaps  is  shown  in 

TJM.  i:>0  and  1^1.     Nove-To-serand  ha<  employed  his  teehnic  for 

the  repair  of  hypospadins  in  these  epispadias  witli  excellent 

results. 


Fu;.    13'_\-  ration 


•   :i  and  Cunningham.) 


Operation*  for  EjnapaiKiu. — In  this  ingenious  operation  the 
new  urethra  is  formed  of  mueous  membrane  obtained  by  dissecting  up 

the  tissues  alxnit  the  infundibuliform  urethral  opening,  and  forming 
these  into  a  canal  whieh  replaees  the  urethral  defect.  The  floor  of  the 
new  urethra  is  made  by  dissecting  up  the  floor  of  the  urethral  groove. 
the  dissection  beginning  at  the  eoronary  suleus.  and  extending  back  to 
the  vesieal  orifice.  The  roof  of  the  urethra  is  formed  from  the  tissue 
above  the  urethral  opening.  The  incision  is  shown  in  Fig.  1^2.  The 
flap  thus  outlined  is  dissected  up  in  the  same  manner  as  dissecting  out 


' rE\I  TA  L   MALFORMA  T! 


1 33. — Beck's  operation  for  epispadias.    Second  step.    (Watson  and  Cunningham.) 


FIG.  134. — Beck's  operation  for  eplspadias.    Third  step.    (Watson  and  Cunningham.) 


_!ls     ANATOMY,   .\\OMALIES  AXD  IX J TRIES  OF   THE  PEXIS 

a  hernial  sac,  with  the  left  index  finger  introduced  into  the  urethral 
opening.  In  this  way  one  avoids  buttonholing  the  flap.  Care  must 
also  be  taken  in  making  the  incision  to  allow  a  flap  long  enough  to  ex- 
tend to  the  tip  of  the  glans  without  undue  tension.  The  two  flaps 
which  are  to  form  the  roof  and  floor  of  the  new  urethra  are  now  sutured 
along  their  edges  into  a  tube  Fig.  133.  The  glans  is  then  perforated 
and  the  end  of  the  new  urethra  is  drawn  into  this  opening  and  sutured 
to  the  margin  of  the  new  meatus  Fig.  134.  The  raw  surfaces  are 
covered  in  the  usual  manner.  In  suitable  cases  the  operation  is  rela- 
tively simple  and  avoids  the  formation  of  fistulas  so  troublesome  in  the 
flap  operation  of  Thiersch.  The  result  in  one  case  by  the  author  of 
the  method  was  most  satisfactory.  This  patient  was  able  to  retain 
his  urine  for  four  hours. 


WOUNDS  AND  INJURIES  OF  THE  PENIS. 

Contusions. — Contusion  of  the  penis  is  characterized  by  excessive 
edema  and  the  extravasation  of  blood  into  the  loose  subcutaneous 
areolar  tissue,  and  is  the  result  of  the  application  of  direct  violence  with- 
out resulting  lesion  of  the  skin.  Such  injuries  are  rare  and  occur  when  the 
penis  is  erect,  the  flaccid  organ  generally  escaping.  They  result  from  any 
common  accident,  as  a  blow,  a  fall,  the  kick  of  a  horse,  the  passage  of  a 
wagon  wheel,  etc.  In  a  personal  case  the  patient  was  struck  by  an  ear 
of  corn  thrown  by  a  companion  in  play.  In  the  curious  case  of  Dufour, 
the  young  man  while  seated,  with  his  penis  erect,  received  a  young 
woman  roughly  on  his  lap.  In  another  case  (Voillemier)  the  man 
caught  his  penis  in  closing  a  bureau  drawer.  Dupuytren  records  the 
case  of  a  drunken  man  who  had  his  penis  caught  under  a  falling  sash 
while  urinating  out  of  the  window. 

The  amount  of  hemorrhage  into  the  tissues  depends  upon  the  extent 
of  the  injury.  This  may  be  slight,  amounting  to  little  more  than  a 
subcutaneous  ecchymosis,  or  it  may  be  abundant  and  simulate  gan- 
grene. In  one  case  (Solignac)  the  dorsal  vein  was  wounded  on  the 
edge  of  the  corsets  during  coitus,  producing  an  abundant  hemorrhage, 
difficult  to  arrest.  If  the  sheath  of  the  cavernous  bodies  is  injured, 
hemorrhage  may  be  very  abundant.  If  the  urethra  is  wounded,  there 
is  always  hemorrhage  from  the  meatus,  and  the  condition  is  a  much 
more  serious  one. 

Treatment. — This  consists  in  the  application  of  hot,  moist  compresses 
and  a  supporting  bandage  to  keep  the  penis  elevated.  Absorption 
takes  place  rapidly,  the  edema  subsides  and  the  discoloration  disap- 
pears. When  a  hematoma  forms  and  is  developing  rapidly,  an  incision 
should  be  made  to  evacuate  the  blood  and  ligate  any  bleeding-point  or 
suture  any  laceration  requiring  it.  If  suppuration  occurs,  this  must  be 
treated  by  free  drainage.  Injury  to  the  urethra  is  more  serious  and 
calls  for  appropriate  treatment  to  prevent  extravasation  of  urine  and 
the  formation  of  a  stricture.  (See  Injuries  of  the  Urethra.) 


WOUNDS  AND  INJURIES  OF   THE  PENIS  219 

Wounds. — The  penis  may  IK-  wounded  accidentally  in  a  great 
variety  of  ways;  it  may  also  be  wounded  maliciously,  as  in  injuries 
inflicted  through  jealousy;  or  intentionally,  as  for  example,  the  self- 
mutilation  practised  by  certain  sects  and  by  insane  patients.  These 
wounds  are  usually  classified  as  punctured,  incised,  lacerated,  and  those 
resulting  from  fire-arms. 

Punctured  Wounds. — Punctured  wounds  are  very  rare,  and  are  caused 
by  bayonet,  sword,  or  foil  thrusts.  In  a  case  described  by  Demarquay 
the  injury  was  due  to  a  fall  on  a  spike.  Malgaigne  saw  a  curious  case 
in  which  an  open  knife  carried  in  the  pocket  severed  the  dorsal  artery 
of  the  penis. 

Incised  Wounds. — Incised  wounds  are  most  often  seen  as  the  result  of 
self-mutilation  by  insane  patients  or  criminal  mutilation  inspired  by 
jealousy.  One  recalls  the  custom  of  the  barbarous  Abyssinians,  of 
emasculating  their  enemies  when  captured,  and  the  practice  among  the 
adherents  of  the  cast  of  Skoptzy  of  cutting  off  the  penis.  Accidental 
injuries  of  this  kind  are  rare;  the  case  of  Nottingham  is  an  exception. 
A  young  sailor  received  a  deep  wound  of  the  glans  during  intercourse 
from  a  piece  of  a  glass  nozzle  which  had  broken  off  in  the  vagina  while 
taking  a  douche. 

Lacerated  Wounds. — These  result  most  often  from  the  bite  of  an 
animal,  for  example  a  horse,  dog,  hog,  etc.  Less  often  they  are  pro- 
duced by  machinery.  Westbrook's13  patient  was  caught  in  a  pulley 
which  tore  the  skin  from  the  pubis,  scrotum,  and  penis.  In  Powers's 
case,  a  lad  of  six  years,  the  injury  occurred  in  climbing  over  a  barbed- 
wire  fence.  The  skin  of  the  penis  was  stripped  off,  turned  inside  out, 
and  hung  at  the  preputial  attachment.  The  nature  of  the  wound 
depends  upon  the  manner  in  which  it  was  produced.  It  may  be  limited 
to  the  integument  which  is  lacerated,  torn,  and  turned  inside  out  like 
the  finger  of  a  glove,  as  in  Powers's27  case,  or  the  deeper  structures  may 
be  implicated.  According  to  Biondi,6  less  force  is  necessary  in  the  pro- 
duction of  lacerated  wounds  when  the  penis  is  erect  than  when  it  is 
flaccid. 

Gunshot  Wounds. — These  are  by  no  means  rare.  They  are  usually 
associated  with  injuries  to  other  organs,  the  bullet  passing  through  the 
penis  or  finding  lodgment  here  after  passing  through  neighboring 
structures.  In  the  Civil  War  Otis  recorded  30  cases.  When  the 
cavernous  bodies  are  pierced,  hemorrhage  is  abundant  and  a  large 
hematoma  may  result.  The  scar  remaining  after  healing  will  interfere 
with  erection. 

Treatment. — In  the  treatment  of  wounds  of  the  penis  one  is  guided  by 
the  general  surgical  principles  applicable  to  wounds  of  other  parts. 
Cleanse  the  wound  and  apply  an  antiseptic  dressing.  Hemorrhage 
should  be  controlled  by  ligating  the  bleeding-point  or  by  suture  of  the 
torn  sheath  of  the  corpora  cavernosa.  When  suppuration  supervenes, 
free  incision  and  drainage  are  demanded.  Healing  of  wounds  of  the  penis 
is  rapid,  owing  to  the  abundant  blood  supply.  Even  in  apparently 
hopeless  cases  an  attempt  should  always  be  made  to  save  the  organ, 


220     A\  ATOMY,   ANOMALIES  AXD  INJURIES  OF   THE   PEXIS 

and  amputation  is  resorted  to  only  when  every  effort  has  resulted  in 
failure.  In  one  case  we  obtained  a  useful  organ  when  this  seemed  to 
be  hopelessly  gangrenous.  ^Yhen  the  urethra  is  involved  in  the  injury, 
this  should  receive  immediate  attention  to  prevent  extravasation  of  the 
blood  and  urine  and  the  subsequent  development  of  a  traumatic 
stricture.  When  the  urethra]  wound  does  not  communicate  with  the 
surface,  a  retention  catheter,  if  this  can  be  introduced,  may  be  all  that 
is  necessary.  Open  wounds  of  the  penile  urethra  require  closure  by 
suture,  and  the  drainage  of  the  urine  through  a  perineal  fistula  will  be 
found  necessary  in  most  cases  for  a  successful  healing  of  these  wounds. 

Rupture  of  the  Penis. — The  terms  rupture  and  fracture  of  the  penis 
are  used  to  designate  the  same  lesion,  namely,  a  tear  in  the  fibrous 
sheath  of  the  corpora  cavernosa.  Strictly  speaking,  fracture  of  the 
penis  in  man  does  not  occur,  since  there  is  normally  no  bone  in  the 
penis.  Among  certain  animals,  as  the  bull  and  the  sea  lion,  there  is  an 
os  penis,  but  fracture  of  this  bone  is  not  observed.  Calcification  some- 
times occurs  in  cases  of  circumscribed  cavernitis  or  Peyrone's  disease, 
and  true  bone  tissue  has  rarely  been  found  as  a  pathological  product  in 
the  human  penis,  as  in  Gerster's  case.10  Rupture  of  the  penis  always 
occurs  during  erection  and  is  usually  due  to  sudden  rough  bending  of  the 
penis  downward  toward  the  thighs.  It  results  from  a  false  pass  in 
coitus,  masturbation,  or  a  direct  blow.  In  Mott's  case  this  accident 
was  due  to  striking  the  erect  penis  against  the  bed-post.  Merkens19 
describes  an  unusual  case  in  which  complete  transverse  subcutaneous 
rupture  of  the  corpus  spongiosum  was  produced  by  accidental  closing 
of  an  open  door  through  which  the  patient  was  urinating.  It  is 
probable  that  the  sudden  increase  in  pressure  during  erection  produced 
by  a  blow  or  sudden  bending  of  the  penis  is  sufficient  to  rupture  the 
normal  fibrous  sheath  of  the  erectile  bodies,  hence  the  accident  plays 
the  chief  role.  In  some  cases,  however,  the  corpora  cavernosa  and  their 
fascial  coverings  are  weakened  by  areas  of  degeneration  resulting  from 
antecedent  disease,  arid  are  therefore  much  more  easily  ruptured.  At 
the  time  of  the  accident  there  is  sudden  pain  at  the  point  of  rupture, 
a  distinct  crackling  sound  is  heard,  the  penis  becomes  flaccid,  and  coitus 
is  interrupted.  In  a  short  time  the  penis  begins  to  swell  from  the 
associated  edema  and  attains  enormous  proportions.  The  acute  pain 
gives  way  to  a  sense  of  fulness;  the  penis  is  bent  sharply  at  the  site  of 
the  tear  toward  the  uninjured  side,  hence  the  rupture  is  always  on  the 
convex  side.  Under  appropriate  treatment  the  swelling  quickly  sub- 
sides; the  ecchymosis  gradually  disappears,  but  a  scar  often  results 
which  interferes  with  erection  and  may  make  coitus  impossible.  Sup- 
puration rarely  occurs,  and  hemorrhage  is  not  often  alarming. 

Treatment. — Elevation  of  the  penis  and  the  application  of  cold  com- 
presses suffices  in  most  cases.  Incision  and  suture  are  rarely  required, 
but  should  not  be  deferred  when  indicated  by  a  progressive  hematoma. 

Dislocation  of  the  Penis. — In  this  exceedingly  rare  accident  the 
body  of  the  flaccid  penis  is  forced  out  of  its  outer  sheath  of  integument 
and  displaced  under  the  skin  of  the  scrotum,  pubes,  or  thigh.  The 


WOU\DS  AND  INJURIES  OF   THE  PENIS  221 

injury  has  been  observed  in  children  as  well  as  adults.  The  mechanism 
of  its  production  is  not  clear  from  the  cases  reported,  but  evidently  the 
body  of  the  penis  is  squeezed  out  of  its  envelope  by  a  force  applied  to 
its  outer  extremity,  the  separation  occurring  at  the  preputial  orifice  or 
more  commonly  along  the  coronary  sulcus.  The  deformity  is  not 
apparent  at  first,  since  the  skin  sheath,  filled  with  a  blood  clot,  may 
present  a  normal  appearance.  Very  soon,  however,  difficult}'  in  urina- 
tion attracts  attention  and  examination  shows  a  sheath  filled  \vith  blood 
and  containing  no  penis.  The  urethra  is  usually  ruptured  in  the  peri- 
neum and  extravasation  of  urine  with  its  attending  symptoms  may 
supervene.  Careful  search  will  always  reveal  the  presence  of  the  organ 
in  its  abnormal  position. 

Treatment. — In  at  least  two  cases  (Nelaton  and  Guth)  the  penis  was 
easily  replaced  in  its  sheath,  with  happy  results.  This  may  be  difficult 
or  impossible,  however,  owing  to  the  edema  and  infiltration,  in  which 
case  incision  will  be  necessary  to  liberate  the  penis  and  permit  its  repo- 
sition in  its  proper  sheath.  In  the  event  of  a  rupture  having  occurred, 
immediate  perineal  section  will  be  necessary. 

Strangulation  of  the  Penis. — This  injury  is  not  at  all  uncommon. 
It  is  seen  in  children  as  the  result  of  a  nurse  tying  a  string  or  cord  about 
the  penis  to  prevent  the  escape  of  urine  in  cases  of  incontinence.  In 
adults,  strangulation  is  produced  by  rings,  bands,  the  neck  of  a  bottle, 
etc.,  used  for  the  purpose  of  masturbation  or  other  sexual  perversions. 
The  extent  of  the  injury  will  depend  upon  the  degree  of  constriction, 
the  amount  of  swelling  of  the  penis,  and  the  length  of  time  the  foreign 
body  is  allowed  to  remain.  As  a  result  of  the  constriction,  the  penis 
swells  rapidly  and  the  constricting  band  is  buried  at  the  bottom  of  a 
deep  groove;  it  is  soon  hidden  from  view  and  may  be  difficult  to  find. 
The  injury  will  vary  from  a  superficial  lesion  of  the  skin  in  the  simplest 
case  to  section  of  the  urethra  and  even  gangrenous  destruction  of  the 
distal  portion  of  the  organ.  With  the  onset  of  swelling,  retention  of 
urine  is  complete  and  is  relieved  only  by  removal  of  the  foreign 
body.  When  this  is  delayed,  the  urethra  ruptures  behind  the  constric- 
tion and  a  fistula  results.  It  is  the  pain  associated  with  the  swelling 
and  especially  the  retention  of  the  urine  which  compels  the  patient  to 
seek  relief,  which  he  usually  does  in  a  few  hours.  Shame  and  fear  of 
detection  may  delay  the  visit  to  a  physician  and  the  patient  postpones 
seeking  relief  for  a  longer  time;  three  weeks,  six  months,  a  year,  or 
even  t\velve  years  in  reported  cases.  The  treatment  consists  in  remov- 
ing the  foreign  body  as  soon  as  possible.  This  is  easily  done  in  the 
case  of  a  thread  or  a  thin  ring.  When  the  foreign  body  is  a  thick  ring 
its  removal  may  require  considerable  patience  and  ingenuity.  In 
Aylen's3  case  it  required  two  hours  to  file  through  a  heavy  iron  ring. 
When  the  urethra  has  been  cut  into,  the  resulting  fistula  must  be  closed 
according  to  the  principles  laid  down  in  the  section  on  Injuries  of  the 
Urethra. 


222     ANATOMY,  ANOMALIES  AND  INJURIES  OF  THE  PENIS 


BIBLIOGRAPHY. 

1.  Aievoli:  Arch.  gen.  de  med.,  Paris,  1906,  ii,  2380. 

2.  Albrecht:  Ztschr.  f.  Path.,   1910,  iv,  475. 

3.  Aylen:  St.  Paul  Med.  Jour.,  1905,  vii,  46. 

4.  Beck:  New  York  Med.  Jour.,  1898,  Ixvii,  147. 

5.  Beck:  New  York  Med.  Record,  March  30,  1907. 

6.  Biondi:  Jahresbericht  f.  Urog.,  1906,  p.  251. 

7.  Caddy:  Lancet,  1894,  ii,  634. 

s.  Cole:  Nashville  Med.  and  Surg.  Jour.,  1894,  Ixxvi,  159. 

9.  Donnet:  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1906,  xxxii,  1002. 

10.  Gerster:  Ann.  Surg.,   1913,  Ivii,  896. 

11.  Harris:  Philadelphia  Med.  Jour.,   1898,  i,  71. 

12.  Hofmokl:  Arch.  f.  klin.  Chir.,  1897,  liv,  220. 

13.  Kaufmann:  Deutsche  Chirurgie,  L,  a,  60. 

14.  Keppel:  New  York  Med.  Jour.,  1898,  Iviii,  710. 

15.  Kiittner:  Beit,  zur  klin.  Chir.,  1895-6,  xv,  364. 

16.  Lebrun:  Journal  d'Urologie,  1912,  ii,  380. 

17.  Lionti:  Deutsche  med.  Wchnschr.,  1914,  xl,  393. 

18.  Matthew:  Quoted    by    Harris. 

19.  Merkeiis:  Deutsche  Ztschr.  f.  Chir.,  1911,  cxi,  313. 

20.  Mocquot:  Bull,  et  Mem.  Soc.  Anat.  de  Paris,  1904,  Ixxix,  344. 

21.  Mummery:  Rep.  Soc.  Study  Dis.  Child.,  London,  1906-7,  vii,  99. 

22.  Neimann:  Quoted  by  Lebrun. 

23.  Nove-Josserand:  Lyon  Med.,  1897,  Ixxxv,  198. 

24.  Ollsner:  Quoted  by  Lebrun. 

25.  Papadopoulos:  These  de  Lyon,  1908. 

26.  Pousson:  Ztschr.  f.  Urologie,  1914,  viii,  440. 

27.  Powers:  Ann.  Surg.,   1909,  xlix,  238. 

28.  St.  Hilaire:  Quoted  by  Lebrun. 

29.  Smith,  Alan  P.:    Transactions  Med.  and  Chir.  Faculty  of  Maryland,  April,  1878. 

30.  Trenkler:  Wicn.  med.  Wchnschr.,  1914,  Ixiv,  1079. 

31.  Trillat:  Arch.  prov.  de  Chir.,  1902,  p.  311. 

32.  Volpe:  II  Policlinico,  fasc.,  1903,  i,  46. 

33.  Westbrook:  Long  Island  Med.  Jour.,  1911,  v,  405- 


CHAPTER  VII. 
DISEASES  OF  THE  PENIS. 

BY  GEORGE  W.  WARREN,  M.D. 

DISEASE  OF  THE  FRENUM. 

A  SHORT  frenum,  which  may  he  classed  as  congenital,  occurs  in  cases 
where  there  is  no  other  malformation.  This  may  interfere  with  com- 
plete emptying  of  the  urethra.  It  may  cause  an  incurving  of  the 
penis  when  the  organ  is  erect.  I  have  seen  cases  where  the  subject 
was  sterile,  due  to  this  marked  incurving,  and  became  fertile  by  simply 
cutting  through  the  frenum.  During  coitus  these  short  frenums  are 
torn  and  the  accident  frequently  results  in  a  marked  hemorrhage,  the 
frenal  artery  being  torn.  Sexual  neurasthenia  in  some  cases  is  caused 
by  these  short  frenums.  Erections  are  very  painful. 

Treatment. — Cutting  through  the  frenum,  and  sewing  together  the 
cut  edges  of  the  wound,  which  causes  a  quicker  union  and  prevents 
hemorrhage,  as  the  frenal  artery  is  caught  by  the  stitch. 

PHIMOSIS. 

Congenital  Phimosis. — The  opening  or  ring  of  the  foreskin  in  this 
condition  is  relatively  to  the  glans  so  small  that  retraction  of  the  fore- 
skin over  the  glans  is  impossible.  There  are  necessarily  several  degrees 
of  this  condition,  from  those  cases  where  the  meatus  of  the  penis  is 
seen  with  difficulty  or  not  at  all  to  those  where  the  foreskin  can  be 
retracted,  but  the  blood  supply  of  the  glans  by  this  act  is  cut  off  or 
impeded. 

In  the  newborn  there  is  a  physiological  phimosis  which  continues 
for  a  longer  or  shorter  time.  The  inner  leaf  of  the  foreskin,  that 
portion  in  contact  with  the  glans,  is  adherent  to  it  by  an  epithelial 
deposit.  This  condition  can  be  relieved  by  separation  with  an  instru- 
ment or  retraction  of  the  foreskin.  If  this  condition  is  allowed  to 
remain,  inflammatory  processes  supervene  and  result  in  adhesions 
between  the  glans  and  foreskin.  As  the  patient  grows  older  this  phy- 
siological phimosis  is  relieved  by  the  orifice  of  the  foreskin  becoming 
larger  at  about  the  second  year,  and  it  generally  takes  the  adult  form 
between  the  years  of  nine  and  thirteen. 

The  normal  foreskin  can  be  retracted  over  the  glans  easily  and  pain- 
lessly when  the  penis  is  in  erection,  and  when  there  is  no  retardation 
of  blood  circulation  while  it  is  thus  retracted. 

Congenital  phimosis  may  exist  with  a  prepuce  of  normal  length  or 

(223) 


224  DISEASES   OF   THE   1'EXJS 

with  one  very  long  or  short.  In  cases  of  long  prepuce  the  glans  is 
covered  with  an  empty  sac  which  lies  in  folds.  Upon  urination  this 
bag  fills  with  urine  and  may  balloon  out  to  the  size  of  an  egg,  and  the 
urinary  stream  issuing  has  little  force. 

The  opening  of  the  foreskin  may  be  so  small  that  a  fine  probe  cannot 
enter  it.  In  these  cases  the  frequent  ballooning  of  the  foreskin  causes 
it  to  become  tremendously  dilated.  This  great  dilatation  causes  a  dis- 
proportion between  the  outer  and  inner  leaf  of  the  foreskin.  The  ring 
of  the  foreskin,  which  is  the  narrowest  portion  of  the  same,  seems  to  be 
retracted  by  the  overhanging  of  the  outer  leaf. 

In  cases  of  short  foreskin  (atrophic  phimosis)  the  prepuce  is  drawn 
tightly  over  the  glans.  Here,  again,  the  opening  of  the  prepuce  may  be 
very  small  and  not  in  line  with  the  meatus.  This  causes  difficulty  in 
urination  and  may  be  a  serious  condition. 

In  both  of  these  conditions,  long  and  short  foreskin,  there  may  be  an 
accumulation  of  epithelial  smegma  and  urinary  sediment,  preputial 
stones,  and  balanoposthitis  may  occur.  These  are  not,  as  one  would 
expect,  constant  sequehe  of  this  condition.  In  both  of  these  lesions, 
when  the  condition  has  existed  for  some  little  time,  there  is  sometimes 
a  trabeculation  of  the  bladder  and  at  times  a  hydronephrosis  with 
dilated  ureters. 

The  urinary  act  is  always  difficult,  and,  as  before  stated,  in  those 
cases  of  short  foreskin  where  its  opening  does  not  correspond  to  the 
meatus,  the  child  strains  and  cries  with  pain  upon  urination.  The 
long  foreskin  may  hold  urine  and  dribble  after  the  urinary  act.  At 
times  the  urine  retained  in  the  foreskin  becomes  infected  and 
decomposes,  and  the  resulting  inflammation  may  cause  urinary 
retention. 

In  adults  phimosis  with  short  foreskin  results  in  a  poorly  devel- 
oped glans  penis,  and  the  sexual  act  is  interfered  with.  Many  of  these 
cases  are  sexual  neurasthenics. 

Retention  of  urine  may  sometimes  occur  in  these  cases  of  phimosis, 
when  upon  this  condition  balanoposthitis  is  superimposed.  All  the 
complications  of  a  balanoposthitis  are  to  be  found  in  these  cases  of 
phimosis,  such  as  erosion,  ulceration  and  perforation  of  glans  and 
foreskin,  stone  formation  under  foreskin,  and  ammoniacal  urine. 

The  dangerous  sequela  of  impediment  of  urination,  in  cases  of 
phimosis,  is  often  underestimated.  In  cases  of  marked  phimosis 
of  children  it  is  not  uncommon  to  find  hernia,  prolapsed  anus,  etc., 
due  to  the  marked  abdominal  pressure  necessary  to  empty  the 
bladder. 

Phimosis  in  Adults :  The  impediment  of  urination  exists,  though  not 
so  apparent  as  in  children.  Dwarfing  of  the  glans  penis;  sexual  neuras- 
thenia may  be  conspicuous  in  these  cases;  balanoposthitis  with  its 
complications  is  common;  and  most  important  is  the  danger  of  cancer 
formation.  Three-fourths  of  all  cases  of  cancer  of  the  penis  reported 
occur  in  cases  of  phimosis. 

Preputial  stones  may  be  a  complication  of  phimosis.     They  generally 


PARAPHIMOSIS  225 

occur  in  children,  but  rarely  in  adults.  Two  types  of  stone  may  exist 
in  phimosis :  true  preputial  stones  which  are  formed  under  the  prepuce, 
and  stones  which  are  formed  in  the  kidney  or  bladder,  and  in  their 
escape  from  the  body  are  caught  in  the  preputial  sac  by  its  narrow 
ring. 

True  preputial  stones  are  formed  from  the  smegma,  epithelial  detritus, 
bacteria,  and  the  salts  of  decomposed  urine.  They  are  light  in  weight, 
soft,  brownish  bodies  without  any  characteristic  shape,  often  being  so 
soft  that  they  mould  themselves  over  the  glans,  even  to  the  extent  of 
covering  it.  When  the  number  of  stones  is  large  they  may  be  faceted. 
Generally  they  are  small  in  size,  but  there  are  exceptions,  one  being 
reported  the  size  of  an  egg.  They  are  multiple,  as  a  rule;  as  many  as 
a  hundred  have  been  reported.  Under  the  microscope  they  are  seen  to 
consist  of  epithelium,  fat  molecules,  cholesterin  crystals,  urinary  salts, 
and  bacteria. 

The  hard,  heavy  stones  sometimes  found  in  this  location  are  formed 
in  the  kidney  or  bladder.  They  often  gain  in  size  by  the  accumula- 
tion of  smegma  and  epithelial  deposits  from  the  foreskin.  Under 
this  layer  of  smegma  and  epithelium  is  found  as  a  nucleus  a  urinary 
stone.  This  nucleus  will  show  the  elements  of  a  true  bladder  or 
kidney  stone. 

These  stones,  as  a  rule,  cause  a  chronic  balanoposthitis,  often  accom- 
panied by  a  thick,  purulent  secretion.  The  penis  may  be  swollen  and 
edematous,  and  the  prepuce  infiltrated.  The  patient  may  suffer  from 
dribbling  of  urine  or  difficulty  in  urination,  and  may  have  frequent 
erections  and  pollutions.  Often  they  suffer  from  defective  erections, 
due  to  pain.  Usually  these  patients  are  not  aware  of  the  presence  of 
a  stone,  although  they  often  feel  a  foreign  body  under  the  foreskin  which 
at  times  impedes  urination  by  wedging  itself  into  the  ring  of  the  fore- 
skin. The  stone  tends  to  ulcerate  through  the  foreskin  in  long-standing 
cases,  resulting  in  fistula  formation.  There  is  danger  in  these  cases  of 
bladder  and  kidney  infection. 

Treatment. — Circumcision. 

PARAPHIMOSIS. 

Paraphimosis  embraces  all  conditions  in  which  the  glans  penis  is 
compressed  or  strangulated  by  the  prepuce.  This  takes  place  when 
the  glans  penis  passes  forward  through  a  comparatively  small  pre- 
putial ring  and  the  ring  in  sliding  back  over  the  glans  drops  into,  and 
is  held  by,  the  sulcus  back  of  the  corona. 

Paraphimosis  can  exist  only  in  cases  in  which  there  is  a  relatively 
moderate  degree  of  phimosis,  and  the  length  of  the  foreskin  must  be 
sufficient  to  allow  it  to  slip  back  behind  the  corona. 

It  is  impossible  for  paraphimosis  to  exist  in  cases  in  which  the  fore- 
skin cannot  be  drawn  back  over  the  glans,  as  in  cases  of  high-grade 
phimosis,  or  in  cases  of  very  short  frenum,  or  where  adhesions  exist 
between  the  glans  and  foreskin. 

M  U      I — 15 


226  DISEASES  OF   THE  PENIS 

This  lesion  occurs,  as  a  rule,  when  the  penis  is  erect.  It  can  take 
place  with  the  penis  flaccid,  but  is  then  usually  accomplished  by  forcibly 
pulling  a  tight  foreskin  back  over  the  glans. 

As  the  inner  leaf  is  closely  adherent  to  the  shaft  of  the  penis  for  some 
little  distance  back  of  the  corona,  one  will  readily  see  that  the  preputial 
ring  cannot  be  in  direct  apposition  to  the  shaft  of  the  penis,  but  is 
separated  from  it  by  this  layer  of  the  inner  leaf.  Only  in  cases  of 
atrophic  phimosis,  where  the  inner  leaf  hugs  the  glans  closely,  does  the 
entire  foreskin  come  back  so  that  the  preputial  ring  lies  in  direct 
apposition  to  the  shaft  of  the  penis. 

In  cases  of  milder  paraphimosis  there  is  only  a  swelling  of  the  glans 
penis,  and  behind  this  is  the  folded  and  swollen  outer  leaf  of  the  prepuce. 
The  preputial  ring  lying  in  the  sulcus  is  hidden  under  this  swelling  of  the 
outer  leaf.  The  swelling  of  the  glans  is,  as  a  rule,  far  more  marked,  and 
it  becomes  edematous  and  discolored.  Behind,  and  at  times  overlying 
it,  is  the  swollen  outer  leaf.  In  the  sulcus,  and  more  than  filling  it, 
is  a  second  swelling,  consisting  of  the  swollen  and  edematous  inner 
leaf.  Only  by  lifting  aside  this  second  swelling  can  the  preputial  ring 
be  seen. 

A  long  or  short  frenum  may  modify  the  character  of  a  paraphimosis. 
A  long  frenum  may  cause  the  constriction  of  the  preputial  ring  to 
occur  behind  the  sulcus. 

The  sequelae  of  this  condition  are  rapid  swelling,  discoloration,  and 
bullse  of  the  tissue,  which  may  go  on  to  necrosis.  This  takes  place  just 
in  the  region  of  greatest  pressure.  Gangrene  of  the  ring  is  rare.  The 
gangrenous  process  generally  confines  itself  to  the  outer  and  inner  leaf, 
sparing  the  cavernous  tissue. 

Paraphimosis  may  relieve  itself  somewhat  by  gangrenous  process  of 
the  preputial  ring.  There  are  cases  reported  in  which  by  numerous 
inflammatory  processes  and  ulcerations  the  preputial  ring  has  been 
enlarged,  thereby  relieving  the  tendency  to  constriction. 

The  systemic  symptoms  are  mild,  patients  often  not  presenting  them- 
selves for  treatment  until  the  condition  has  existed  for  several  days. 

Treatment. — In  most  cases  the  swollen  glans  can  be  compressed 
between  the  fingers  until  it  can  be  pushed  back  through  the  ring. 
When  this  cannot  be  done  the  constriction  should  be  relieved  by 
incision  of  the  preputial  ring.  Circumcision  may  be  performed  after 
the  swelling  has  subsided. 

SUBCUTANEOUS  INJURIES  OF  PENIS. 

Pain  may  be  very  intense  even  in  slight  injuries,  and  may  cause 
the  patient  to  faint.  The  bleeding  following  these  contusions  is  very 
noticeable,  even  in  superficial  contusions,  and  the  resulting  ecchymosis 
spreads  over  the  pubic  region,  scrotum  and  perineum,  as  well  as  the 
shaft  of  the  penis. 

The  discolorations  of  skin  due  to  this  deep  extravasation  of  the  blood 
appear  in  a  cherry  or  blue  red,  while  the  subcutaneous  extravasation 


SUBCUTANEOUS  INJURIES  OF  PENIS  227 

appears  as  a  dark  blue.  This  extravasation,  as  a  rule,  spreads  from  the 
deep  to  the  superficial  coverings  of  the  organ,  and  extends  over  a 
large  area.  The  point  of  most  marked  extravasation  is  the  point  of 
greatest  induration.  Subcutaneous  tearing  of  the  penis  involving  the 
corpora  cavernosa  takes  place  only  when  the  penis  is  erect  or  when 
the  corpora  cavernosa  are  involved  by  inflammation,  causing  a  tight- 
ening of  the  connective  tissue.  Formerly  this  was  called  fracture  of 
the  penis.  This  is  not  a  true  fracture,  as  sometimes  happens  in  lower 
animals,  in  which  an  os  penis  exists;  but  in  man  a  growth  of  bone 
occurs  only  as  a  rare  pathological  condition.  So-called  fracture  is  a 
tear  of  the  cavernous  tissue.  This  tear,  as  a  rule,  extends  through 
the  albuginea  (the  fibrous  covering  of  the  cavernous  body),  which, 
when  the  penis  is  flaccid,  is  over  2  mm.  in  thickness  and  very  tough, 
and  when  the  penis  is  erect,  is  spread  out  to  a  thinness  of  0.25  mm. 
(Henle).  The  force  causing  the  injury,  as  a  rule,  is  delivered  in  line  of 
the  long  axis,  rarely  in  the  transverse.  The  injury  is  rare  during 
coitus,  but  may  take  place  if  the  organ  strikes  outside  the  vaginal 
orifice.  It  is  more  often  due  to  a  blow  by  a  falling  body  or  the  pushing 
of  the  penis  against  some  foreign  body,  or  by  forcibly  bending  back 
the  organ.  So-called  fracture  may  result  when  the  patient  tries  forcibly 
to  correct  the  deformity  resulting  from  chordee,  in  which  case  it  is 
almost  always  limited  to  the  corpus  spongiosum. 

Symptoms. — The  symptoms  of  fracture  are  similar  to  those  resulting 
from  a  grave  injury  to  the  urethra.  Inability  to  void  often  exists  when 
the  urethra  is  not  injured.  This  is  due  to  the  pressure  on  the  urethra 
from  blood  extravasation.  The  absorption  of  the  blood  is  rapid. 

Diagnosis. — In  this  instance  diagnosis  is  apparent.  The  deformity 
of  the  penis,  as  a  rule,  is  corrected  by  the  patient,  but  even  in  these 
cases  where  the  deformity  has  been  corrected  one  may  feel  the  break  in 
the  albuginea  and  corpora  cavernosa.  At  this  point  there  is  a  marked 
induration  and  the  blood  clots  creak  under  the  touch.  The  pain  is 
intense. 

Prognsois. — The  prognosis  depends  upon  the  presence  or  absence  of 
complications.  In  some  cases  the  blood  is  quickly  absorbed  from 
the  parts  and  the  blood  spaces  of  the  cavernous  body  are  freed.  In 
these  cases  th.e  function  of  the  penis  remains  normal.  In  other  cases 
this  does  not  take  place  and  a  hard  infiltration  remains  in  the  cavernous 
body.  This  causes  either  a  crooking  of  the  penis  or  else  that  part  of 
the  organ  in  front  of  the  fracture  remains  flaccid  when  the  organ  is 
erect. 

If,  as  a  complication,  we  have  an  infection,  gangrene  and  partial 
loss  of  the  organ  may  result. 

Treatment. — In  cases  in  which  the  urethra  is  not  involved,  a  simple 
dressing  with  a  splint  is  sufficient,  care  being  taken  to  have  a  free  pas- 
sage for  the  urine.  Where  the  extravasation  is  absorbed  slowly,  or  the 
blood  clot  becomes  infected,  drainage  becomes  necessary. 


228  DISEASES  OF   THE  PEXIS 


OPEN  WOUNDS  OF  THE  PENIS. 

Tearing  and  contusions  are  more  often  the  cause  of  open  wounds  of 
the  penis  than  biting,  shot,  cut,  or  stab  wounds. 

The  most  common  tearing  wound  is  of  the  frenum;  also  the  tear  of 
the  prepuce  in  cases  of  phimosis  is  common.  In  rare  cases  the  whole 
organ  is  torn  off,  as  where  the  parts  have  been  caught  in  machinery, 
etc.  It  is  rare  to  have  the  skin  torn  from  the  organ,  but  it  does  occur. 
In  these  cases  the  skin  is  stripped  from  the  root  of  the  penis  and 
rolled  up  forward. 

Luxatio  penis  is  a  condition  which  is  frequently  described,  though 
not  common,  but  the  resulting  condition  is  of  serious  consequence. 
The  skin  of  the  penis  is  torn  through  at  the  inner  leaf  of  the  foreskin  at 
the  sulcus  coronalis  and  the  denuded  penis  is  liable  to  slip  back  from  its 
skin  envelope  and  is  lost  under  the  skin  of  the  scrotum  or  pubis.  These 
cases,  as  a  rule,  are  due  to  violence,  but  may  follow  ritual  circumcision. 
The  condition  resembles  the  so-called  congenital  anomaly  (phimosis 
scrotalis)  in  which  the  penis  lies  under  the  skin  of  symphysis  pubis 
or  scrotum.  The  patient  directly  after  the  accident  presents  a  short 
skin  sac,  often  filled  with  blood  clot,  which  can  be  easily  emptied  by 
pressure.  It  is  sometimes  difficult  to  find  the  shaft  of  the  penis.  The 
urine  is  emptied  either  through  the  skin  sac  or  from  some  neighboring 
skin  wound.  Urination  is  necessarily  interfered  with  and  as  it  takes 
the  path  of  least  resistance  the  tissues  may  become  infiltrated.  After 
a  short  time  the  shaft  of  the  penis  becomes  fixed  in  its  abnormal 
position  by  scar  tissue. 

Wounds  in  which  a  portion  of  the  skin  has  been  stripped  off,  and  even 
when  there  is  loss  of  tissue,  heal  readily  and  rarely  lead  to  death. 
Nevertheless,  the  resulting  scars  often  cause  contractions  and  the  dis- 
torted penis  may  be  of  little  value  functionally. 

Treatment. — Fresh  wounds  of  the  frenum  should  be  sutured  immedi- 
ately with  fine  thread.  The  stitch  should  include  the  frenal  artery. 
In  older  cases  which  have  been  infected  it  is  better  to  clean  the  part  and 
treat  by  wet  dressings  before  plastic  work  is  begun,  as  the  swelling  which 
is  always  present  will  by  these  means  be  reduced  and  thus  the  ultimate 
result  is  better. 

The  so-called  luxatio  penis  should  be  reduced  at  once,  the  denuded 
penis  placed  in  the  skin  sac  and  held  by  loose  stitching.  Urinary  fis- 
tulse  should  be  excised  freely  and  drained,  and  the  whole  covered 
by  wet  dressing. 

As  a  rule  these  cases  require  several  operations  before  a  satisfactory 
result  is  obtained.  In  those  of  long  standing  in  which  the  shaft  has 
been  caught  and  held  by  scar  tissue  in  its  abnormal  position  one  finds 
great  difficulty  in  locating  it.  The  guide,  naturally,  is  the  existing 
urinary  sinus,  as  it  must  lead  to  the  meatus  of  the  penis.  Thus  one 
opens  these  sinuses  freely  and  dissects  back  to  the  hidden  shaft.  After 
the  shaft  is  quite  freed  it  is  placed  in  its  skin  envelope  as  in  fresh  cases. 


STRANGULATION  OF  PENIS  BY  FOREIGN  BODIES      229 

Healing  in  these  instances  is  usually  good,  except  when  infected  or 
neglected. 

In  those  cases  in  which  the  skin  has  been  torn  it  should  be  united  by 
stitches  at  once.  Drainage  should  be  instituted  in  those  where  there 
has  been  marked  maceration  or  when  a  great  amount  of  dirt  has  been 
driven  into  the  wound.  When  there  is  loss  of  tissue,  plastic  work 
should  be  instituted  at  once,  as  the  resulting  scars  of  neglected  cases 
cause  marked  distortion  of  the  penis,  which  can  be  corrected  only  with 
the  greatest  difficulty. 

Contusions  of  the  penis  are  similar  to  subcutaneous  contusions 
already  described,  but  are  of  greater  intensity,  and  often  involve  the 
scrotum  and  perineum.  They  are  accompanied  by  shock.  The  prog- 
nosis of  contusions  depends  upon  how  early  the  case  is  seen  and  upon 
the  absence  or  presence  of  complications,  such  as  infiltrations  and  scar 
formations.  When  there  is  injury  to  the  urethra  a  catheter  should 
be  passed  into  the  bladder  and  retained  there.  There  should  be  an 
immediate  attempt  to  repair  all  wounds. 

Wounds  of  the  penis  resulting  from  bites  are  usually  severe  and  are 
due  to  attacks  by  animals.  Insect  bites  are  serious  only  as  the 
resulting  swelling  and  infection  may  lead  to  gangrene  of  the  part. 

BURNS  AND  FREEZING  OF  THE  PENIS. 

Burns  are  treated  as  elsewhere  on  the  body. 

Freezing  of  the  penis  is  very  rare.  The  symptoms  are  the  same  as 
for  other  parts  of  the  body.  The  scratching  of  the  patient,  due  to  the 
intense  itching,  may  cause  an  infection  and  consequent  chronic  inflam- 
mation. There  is,  as  a  rule,  a  lowr-grade  urethritis  and  balanoposthitis 
in  these  cases.  The  part  is  afterward  sensitive  to  cold  and  heat,  as  is 
seen  in  cases  of  frozen  ears. 

STRANGULATION  OF  PENIS  BY  FOREIGN  BODIES. 

This  is  not  a  very  rare  condition,  and  is  due  to  the  application  of 
ligatures  or  other  encircling  bodies.  Hair  is  the  most  common,  and 
with  children  is  sometimes  applied  by  the  mother  or  servant  with  the 
belief  that  it  will  stop  bed-wetting.  When  ligatures  are  used  by  older 
people,  which  is  rather  common,  they  are  used  with  the  idea  of 
increasing  erection  or  to  prevent  nocturnal  pollutions. 

Many  tubular  articles  are  used  by  the  weak-minded  and  mastur- 
bators.  There  is  a  large  variety  of  these  instruments.  They  are 
applied  to  the  penis  before  or  during  erection,  and  are  at  times  re- 
moved with  the  greatest  difficulty,  as  the  constriction  of  the  enveloping 
instruments  allows  ingress  of  arterial  blood  and  obstruction  to  outflow 
of  venous  blood. 

In  my  experience  the  ligature,  especially  the  ligature  of  hair,  is  by  far 
the  most  commonly  met  with.  This  ligature  is  generally  applied  just 
at  the  corona  and  soon  causes  a  marked  constriction.  In  a  few  days 


230  DISEASES  OF   THE  PEXIS 

it  is  rather  a  difficult  matter  to  determine  the  cause  of  the  strangulation, 
as  the  peripheral  end  of  the  penis  becomes  swollen  and  soon  the  liga- 
ture cuts  through  the  skin  and  underlying  connective  tissue.  The 
prepuce  is  inflamed  by  the  resulting  infections  and  takes  on  a  markedly 
swollen,  angry  appearance.  The  edema  makes  it  hard  to  find  a  hair 
ligature,  even  in  an  early  case;  but  later,  when  it  has  cut  into  the  tissues 
and  is  covered  with  granulations,  it  is  most  difficult.  The  constriction 
at  this  time,  if  a  non-elastic  ligature  is  used,  is  lessened,  and  a  child 
may  carry  such  a  ligature  for  weeks.  If  not  removed  it  is  at  times 
covered  by  scar  tissue  from  the  healing  of  the  wound  of  entrance.  It 
may  then  cause  no  further  trouble  and  be  carried  thus  in  its  connec- 
tive-tissue retainer  for  years.  If  the  ligature  cuts  into  the  urethra 
there  is  a  resulting  fistula. 

Solid  rings  applied  to  the  flaccid  penis  are  firmly  caught  by  the  result- 
ing erection.  The  penis  becomes  markedly  swollen,  due  to  the  obstruc- 
tion to  the  return  flow  of  the  blood.  Gangrene  of  the  tissue  is  the 
result.  Systemic  symptoms  in  these  subjects  are  not  marked. 

ACUTE  INFLAMMATORY  PROCESSES. 

Edema  of  the  foreskin  accompanies  all  acute  inflammatory  affections 
and  local  mechanical  interference  with  circulation.  This  mechanical 
interference  may  be  due  to  a  tight-fitting  dressing,  or  ligature,  or  to  con- 
striction due  to  contraction  of  scar  tissue.  In  cases  of  general  edema 
of  the  organ  it  is  more  marked  at  the  prepuce  and  most  marked  at  the 
frenum.  The  under  surface  of  the  penis  shows  the  least  edema.  Edema 
of  the  glans  is  first  seen  on  its  under  surface  in  the  line  of  the  attach- 
ment of  the  frenum  to  the  orifice  of  the  urethra.  When  this  edema 
continues  the  glans,  being  held  firmly  by  the  attachment  to  the  frenum, 
can  swell  only  on  its  upper  surface,  and  this  causes  the  demarcation  of 
the  glans  and  frenum  to  be  obliterated.  The  edema  is,  as  a  rule,  more 
marked  on  one  side  and  then  the  organ  is  bent  in  the  opposite  direc- 
tion. In  cases  of  marked  edema,  urination  at  times  is  interfered  with. 
After  dorsal  or  lateral  incision  of  foreskin,  there  often  exists  a  chronic 
edema  of  the  flaps. 

Acute  inflammation  of  the  glans  (balanitis)  and  foreskin  (posthitis) 
are  rarely  separate  and  will  be  treated  together  as  balanoposthitis. 
The  most  common  form  of  this  is  due  to  gonorrheal  infection.1  Other 
infections  are  divided  by  some  writers  into  catarrhal,  croupous,  diph- 
theritic, and  diabetic.  The  diabetic  is  a  complication  of  diabetes. 
All  cases  of  balanoposthitis  are  due  to  filth,  an  irritating  foreign  sub- 
stance retained  under  the  foreskin  causing  inflammation.  Men  without 
a  foreskin  never  have  balanoposthitis,  as  the  mucous  membrane  by 
exposure  is  converted  into  epidermis. 

1  Although  gonorrhea  is  the  exciting  cause  in  this  condition  there  are  no  gonococci  in 
the  secretion  from  the  foreskin,  the  infection  of  the  foreskin  being  due  to  another 
organism. 


231 

Etiology. — The  cause  is  any  form  of  irritation  which  may  lead  to 
inflammation  of  the  mucosa  of  the  glans  and  foreskin.  The  most  com- 
mon is  the  retention  and  decomposition  of  the  secretion  of  Tyson's 
sebaceous  glands;  the  accumulation  of  gonorrheal  pus;  the  products  of 
hard  or  soft  chancroidal  growth;  and  eczema  or  herpes  of  the  glans  and 
foreskin.  To  all  these  causes  must  be  added  uncleanliness,  as  one 
never  finds  balanoposthitis  when  the  parts  are  kept  clean. 

Symptoms. — The  first  symptoms  are  burning  and  itching.  The  fore- 
skin soon  becomes  swollen,  often  to  such  an  extent  that  it  cannot 
be  drawn  back  over  the  glans.  There  is  an  increased  secretion,  due 
to  irritation.  This  may  be  of  a  purulent  nature,  and  may  be  so  pro- 
fuse that  it  drops  from  the  foreskin.  The  meatus,  if  it  can  be  seen, 
appears  swollen,  as  well  as  the  lining  of  the  foreskin  and  the  covering 
of  the  glans  penis.  Lymphangitis  is  generally  present.  The  dorsal 
lymphatics  are  outlined  in  red  lines  and  are  swollen  and  painful 
to  the  touch. 

As  this  inflammatory  process  continues  there  is  erosion  of  the  epithe- 
lium covering  the  parts,  which  may  lead  to  ulceration.  In  severe  cases 
the  foreskin,  as  a  whole,  is  edematous  and  swollen,  and  if  retracted 
over  the  glans  penis  and  not  reduced,  may  lead  to  gangrene. 

Recurrence  of  balanoposthitis  leads  to  infiltration  and  increase  of 
connective  tissue  in  the  foreskin,  which  may  be  so  great  that  it  is 
impossible  to  retract  it.  Other  complications  are  the  formation  of 
adhesions  between  the  glans  and  foreskin,  as  well  as  preputial  stones. 

Balanoposthitis  is  more  common  in  children,  especially  at  time  of 
puberty,  and,  as  above  stated,  is  due  to  lack  of  cleanliness.  In  older 
people,  when  phimosis  is  present,  a  large  number  will  be  found  to  have 
a  keratosis,  or  so-called  venereal  warts.  The  danger  of  malignant 
changes  in  them  is  very  great.  (See  Carcinomata.) 

Treatment. — Remove  the  irritating  agent  and  keep  the  parts  clean. 
Circumcision  is  advisable  in  cases  of  phimosis  after  the  inflammation 
has  subsided.  If  erosions  are  present  after  circumcision,  one  had 
better  use  a  salve  with  boric  acid  or  one  containing  0.5  per  cent, 
silver  nitrate. 

As  stated  above,  balanoposthitis  is  one  of  the  complications  of  dia- 
betes, and  is  often  due  to  the  sugar-charged  urine  remaining  under  the 
foreskin.  This  is  a  favorable  medium  for  bacterial  growth,  and  when 
this  takes  place  the  itching,  edema,  swelling,  and  increased  secretion 
of  Tyson's  glands  are  present,  as  in  uncomplicated  balanoposthitis. 
These  subjects  having  a  reduced  resistance  against  infection,  the  cover- 
ing of  the  parts  soon  ulcerates  and  infiltration  of  the  organ  follows. 
The  phimosis  and  scar  retraction  are  often  marked.  The  diagnosis  is  at 
once  suggested  by  finding  sugar  in  the  urine. 

Herpes  Progenitalis. — Herpes  progenitalis  manifests  itself  in  an  erup- 
tion of  blisters  containing  a  water-like  fluid.  These  blisters  may  be 
single  or  in  groups.  They  occur  usually  on  the  retroglandular  surface 
behind  the  sulcus,  but  may  appear  on  the  shaft  of  the  penis.  They 
have  been  reported  as  involving  the  urethra  in  their  extension.  These 


232  DISEASES  OF   THE  PEMS 

water-like  blisters  soon  become  infected,  and  then  their  contents 
become  white  and  cloudy.  The  breaking  of  the  blister  causes  ulcer 
formation.  The  inflammation  soon  subsides  and  the  ulceration  heals. 
Often  there  is  a  painful  inguinal  adenitis  as  a  complication. 

Certain  of  these  cases  have  neuralgic  symptoms,  as  in  herpes  zoster. 
In  these  instances  a  day  or  two  before  the  eruption  there  is  marked 
pain  and  soreness  to  the  touch  of  the  skin  of  the  penis  and  scrotum, 
the  pain  sometimes  radiating  to  the  glans  penis.  This  symptom  dis- 
appears as  the  vesicles  appear. 

Treatment. — Cleanliness,  and  a  saturated  solution  of  argyrol  in 
ichthyol  to  paint  over  the  eruption,  and  bandage  with  dry  dressing. 

Cause  is  unknown,  although  the  vesicles  seem  to  follow  the  nerve 
fibers.  Cases  show  a  marked  tendency  to  recurrence. 

Erysipelas. — Erysipelas  of  the  penis  is  rarely  primary.  If  primary, 
it  is  due  to  infection  with  a  streptococcus  through  some  abrasion 
in  the  penis. 

SKIN  AFFECTIONS  OF  THE  PENIS. 

Skin  affections  in  general  may  involve  the  penis  and  ought  to  be 
considered  in  connection  with  the  original  disease.  The  most  common 
of  the  skin  lesions  occurring  on  the  penis  are  psoriasis,  scabies,  herpes, 
a  leukoplakia  preputialis,  described  by  Schuchardt,  and  venereal 
ulcers. 

PHLEGMONS  OF  THE  PENIS. 

Circumscribed  inflammations  of  the  penis  are  noted  in  connection 
with  eczema,  erysipelas,  variola,  typhus,  and  infectious  diseases  of 
severe  type. 

Although  the  above  are  to  be  mentioned,  the  majority  of  phlegmons 
are  secondary  to  traumatism  or  to  extensions  from  inflammatory 
processes  in  the  urethra,  also  after  urinary  infiltrations,  as  well  as  after 
ulcerations,  insect  bites,  erysipelas,  etc. 

These  phlegmons  may  be  accompanied  by  gangrene  of  the  skin.  In 
such  cases  the  dorsal  lymph  channels  are  prominent  and  painful. 
There  is  a  painful  adenitis  in  the  groin.  Of  the  causes  of  this  gangrene 
little  is  known. 

Symptoms. — The  condition  starts  in  a  typical  manner.  There  is  at 
first  slight  local  pain  and  redness.  In  more  severe  cases  vomiting 
and  fever  are  early  symptoms.  The  penis,  and  often  the  scrotum,  are 
swollen.  At  the  end  of  about  twenty  hours  there  appear  numerous 
gangrenous  spots  on  the  skin.  These  quickly  coalesce  and  total  necrosis 
of  the  skin  of  the  penis  and  scrotum  results.  This  is  not  a  deep-seated 
process,  but  at  times  results  in  abscesses  of  the  parts.  Often  the  lymph 
glands  in  the  neighborhood  suppurate  and  abscesses  extend  to  the 
abdominal  wall.  In  severe  cases  the  gangrene  becomes  demarcated 
in  a  few  days  and  the  symptoms  improve.  Recovery  is  the  rule, 
although  rarely  death  occurs  due  to  general  asepsis. 

Treatment. — Incision  for  drainage  and  wet  dressings. 


PHLEGMONS  OF-  THE  PENIS  233 

Acute  Cavernositis. — Acute  cavernositis,  an  infection  localized  in  the 
cavernous  bodies,  must  be  differentiated  from  a  superficial  phlegmon. 

Etiology. — Acute  cavernositis  is  due  to  injuries,  extravasation  of  urine 
into  the  cavernous  bodies  in  cases  of  stricture  and  infected  thrombosis 
which  occurs  in  certain  blood  diseases,  as  leukemia. 

Symptoms. — At  the  onset  an  irregular,  hard,  painful  mass  is  felt 
which  can  be  localized  in  the  cavernous  body.  There  is  painful  and, 
at  times,  difficult,  urination,  due  to  the  extension  of  the  process  to  the 
urethra.  Suppuration  soon  occurs  and  then  a  fluctuating  swelling 
takes  the  place  of  the'hard  mass  formerly  felt.  In  neglected  cases  the 
abscess  may  break  into  the  urethra  or  through  the  skin  of  the  penis. 
As  stated  above,  traumatism  and  the  complications  of  stricture  are  the 
causes  of  the  infection.  (This  type  of  cavernositis  is  often  spoken  of 
as  periurethral  abscess.)  But  it  may  be  hematogenous  in  origin,  as  it 
occurs  in  cases  of  septicemia. 

Diffuse  Cavernositis. — The  rarer  and  much  severer  type  of  caver- 
nositis, the  so-called  diffuse  idiopathic  cavernositis,  is,  in  my  belief, 
always  hematogenous  in  origin  and  is  due  to  pyemic  metastasis. 
These  patients  rarely  recover. 

Diffuse  cavernositis  begins  writh  marked  systemic  symptoms:  chills, 
high  fever  and  marked  swelling  of  the  prepuce.  Priapism  is  a  char- 
acteristic symptom  and  is  present  by  the  third  day  of  infection.  The 
erections  may  be  complete  or  partial,  may  last  for  long  periods 
and  cause  difficulty  of  urination.  Priapism  may  be  due  to  physio- 
logical irritation  of  cavernous  bodies  or  to  a  thrombosis  of  the  same. 
The  latter  is  painless  and  is  generally  followed  by  gangrene  of  the  penis. 
These  infections  at  times  go  on  to  abscess  formation  and  they  may  rup- 
ture into  the  urethra.  Untreated  cases  of  a  few  days'  standing  show 
symptoms  of  pyemia.  Death  is  not  uncommon.  At  autopsy  the 
lungs,  liver  and  kidneys  contain  abscesses.  The  penis  may  remain 
erect  after  death,  held  in  this  position  by  the  thrombosis  of  the  caver- 
nous bodies.  Cases  which  recover  may  have  nothing  of  the  penis  left 
but  a  mass  of  scar  tissue. 

Cases  have  been  reported  of  diffuse  gangrene  of  the  penis  which  is  due 
to  thrombosis  of  its  bloodvessels.  This  thrombosis  may  extend  from 
the  iliac,  femoral,  and  periprostatic  veins. 

Chronic  Cavernositis. — Chronic  cavernositis  may  follow  acute  caver- 
nositis. In  these  cases  scar  tissue  replaces  that  portion  of  the  caver- 
nous body  which  previously  was  the  site  of  inflammation.  Another 
group  of  these  chronic  cases  never  present  any  acute  symptoms.  The 
inflammatory  process  begins  as  a  small,  irregular  swelling,  generally  on 
the  dorsum  of  the  penis  and  often  near  the  symphysis.  The  masses 
vary  in  size,  are  generally  small  and  may  be  multiple.  There  is  a 
tendency  for  this  chronic  process  to  develop  connective  tissue.  In  this 
manner  more  or  less  of  the  cavernous  body  is  replaced  by  connective 
tissue.  This  naturally  causes  a  bending  of  the  shaft  when  the  organ 
is  erect.  The  distortion,  as  well  as  the  pain  upon  erection,  may  cause 
impotency. 


234  DISEASES  OF   THE   PENIS 

Cases  reported  in  literature  of  bony  formation  in  the  human  penis 
are  probably  the  calcification  of  these  connective-tissue  masses. 

Etiology. — Causes  are  many — tearing  of  tunica  albuginea,  intra- 
cavernous  extravasation,  periurethritis,  syphilis,  and  gout. 

GANGRENE  OF  THE  PENIS. 

Ordinary  gangrene  of  the  penis  follows  traumatism  and  inflammatory 
processes,  as  before  stated.  It  also  is  caused  here,  as  in  other  parts  of 
the  body,  by  loss  of  blood  supply,  burns,  etc.  Infiltration  of  urine  with 
its  resulting  infection,  deep-seated  infections  in  the  perineum  are  also 
peculiar  causes  of  gangrene  of  the  penis. 

There  is  an  acute  progressive  gangrene  of  the  penis  and  scrotum 
described  by  Fournier,  Kellemont  and  others,  which  occurs,  apparently, 
without  any  specific  predisposing  cause  and  has  no  analogue  in  other 
organs.  It  may  occur  in  persons  suffering  with  diabetes,  typhus  and 
after  cantharides  poisoning.  At  times  it  occurs  without  any  disease 
being  present.  It  may  follow  bandaging  of  the  penis  after  the  bandage 
has  been  wet  with  urine,  also  after  adhesive  bands  have  been  used  on 
the  penis  to  hold  a  retention  catheter  in  the  urethra. 

Treatment. — Treatment  is  the  same  as  for  gangrene  from  other 
causes — incision  and  drainage. 

LYMPHATICS  AND  BLOODVESSELS. 

Diseases  of  the  bloodvessels  and  lymphatics  are  rare.  Traumatic 
aneurysm  of  the  dorsal  artery,  being  the  most  common  of  these  con- 
ditions. 

CARTILAGINOUS  AND  BONY  FORMATION. 

True  bone  formation  is  found  in  the  penis  of  some  of  the  lower 
animals.  In  man,  thickened  fibrous  tissue  takes  the  place  of  this  bone. 
By  careful  examination  this  fibrous  tissue  can  be  felt  normally. 

Pathologically,  in  old  people,  the  tunica  albuginea  may  become 
infiltrated  with  a  calcareous  deposit,  which  resembles  bone.  The 
symptoms  accompanying  the  condition  are  pain  and  distortion  of  the 
penis  when  erect.  This  distortion  is  similar  to  a  chordee,  with  the 
concavity  in  the  direction  of  the  infiltration.  Other  causes  than  old 
age,  held  by  some  writers,  are  injury  to  the  cavernous  bodies  involving 
the  albuginea,  chronic  cavernositis,  syphilitic  lesions  of  cavernous 
body,  and  gout.  There  is  doubt  in  the  minds  of  many  whether 
these  latter  so-called  etiological  factors  can  be  proven.  Undoubtedly, 
senility  is  the  most  common  cause,  as  the  pathological  process  in 
this  location  resembles  senile  processes  in  other  parts  of  the  body. 

TUBERCULOSIS  OF  THE  PENIS. 

Primary  tuberculosis  of  the  penis  in  adults  is  very  rare.  The  glans 
is  more  often  involved  than  the  prepuce.  It  is  a  chronic  process  from 


GUMMA   OF  THE  PENIS  235 

the  start  and  manifests  itself  by  the  formation  of  granulation  tissue, 
which  gradually  infiltrates  the  surrounding  substance  and  may  invade 
the  whole  thickness  of  the  penis.  This  infiltrate  undergoes  caseation. 

The  infection  may  be  acquired  by  coitus  with  a  female  having 
tubercular  genitals  or  by  direct  infection  with  tubercular  sputum. 
As  the  infection  progresses,  isolated  masses  can  be  felt  in  the  caver- 
nous bodies  and  urethra.  They  are  often  the  size  of  a  pea  and  as 
they  enlarge  they  extend  toward  the  surface  and  are  felt  directly 
under  the  skin.  On  section  they  are  seen  to  foe  masses  of  caseous 
tubercles.  Their  growth  is  slow,  but  eventually  the  skin  of  "the 
penis  is  involved  with  a  resulting  ulceration.  In  this  state  one  may 
mistake  the  infection  for  a  hard  chancre.  Although  this  infection  is 
undoubtedly  autogenous  in  the  great  majority  of  cases,  the  primary 
lesion  may  not  be  in  the  genito-urinary  tract.  The  penis  may  be  the 
seat  of  a  secondary  infection  in  cases  where  there  is  a  tubercular  in- 
fection of  the  kidney  and  bladder.  These  are  rare,  but  when  they 
occur,  the  meatus  at  first  presents  a  swollen,  angry  appearance,  and 
small  miliary  tubercles  are  seen  over  the  surface.  The  adjacent  tissue 
is  slightly  infiltrated.  There  is  a  seropurulent  secretion.  The  whole 
picture  is  very  much  the  same  as  that  presented  by  the  mouth  of  a 
ureter  which  has  been  infected  by  a  tubercular  kidney. 

Tuberculosis  of  the  penis  in  young  children  is  far  more  common  and 
is  often  due  to  direct  infection  at  the  time  of  circumcision  by  the 
rabbi. 

The  old,  orthodox  circumcision  was  performed  by  tearing  the  fore- 
skin free  from  the  penis  by  the  finger-nail,  and  the  resulting  hemor- 
rhage was  stopped  by  sucking  the  penis  with  the  mouth.  This  was 
at  times  performed  by  a  rabbi  with  infected  sputum.  The  incu- 
bation period  in  these  cases  is  about  two  weeks.  It  manifests  itself  as 
a  tubercle,  being  the  typical  yellowish  or  gray-white  speck  on  a  surface 
of  granulation  tissue.  These  infections  progress  rapidly;  the  inguinal 
glands  are  involved  early.  The  patients  always  die  either  by  a  general 
tubercular  infection  or  by  marasmus.  A  few  cases  are  reported  where 
the  wounds  healed,  but  after  two  or  three  years  death  resulted  from 
tuberculosis  of  some  internal  organ. 

Treatment. — Although  the  tubercular  organism  is  often  not  found  in 
the  tissue,  one  can,  as  a  rule,  demonstrate  the  organism  if  a  deep  section 
of  the  tissue  is  carefully  stained.  Excision  or  amputation  of  the  dis- 
eased tissue  is  the  safest  procedure. 

GUMMA  OF  THE  PENIS. 

Gumma  of  the  penis  may  be  located  in  any  of  its  anatomical  divisions. 

When  located  in  the  connective  tissue  just  under  the  skin,  it  may  have 
the  appearance  of  an  enlarged  lymph  gland,  but  as  there  are  no  lymph 
glands  in  the  penis,  one  should  be  on  one's  guard.  These  masses  are 
prone  to  break  down,  and  may  result  in  urinary  fistula  and  stricture. 

No  pain  accompanies  this  lesion. 


236  DISEASES  OF   THE   /'A'.Y/.S 

ACTINOMYCOSIS. 

This  is  a  very  rare  pathological  lesion.  In  the  cases  reported,  pain 
is  an  early  symptom,  and  there  is  a  redness  of  the  meatus  which  is 
soon  followed  by  a  serosanguineous  secretion.  In  the  accompanying 
induration  there  are  small,  purulent,  knotty  masses.  These  soon 
ulcerate  through  the  skin  so  that  the  glans  penis  is  covered  with  many 
small  holes. 

Amputation  is  the  only  treatment. 

ELEPHANTIASIS. 

True  elephantiasis  of  the  penis  is  due  to  infection  with  filaria.  Nat- 
urally these  cases  occur  in  countries  in  which  the  disease  is  endemic. 
Here  the  only  cases  which  have  come  to  my  notice  are  among  emigrants. 
A  great  many  were  from  St.  Kits,  West  Indies. 

The  swelling  may  begin  in  the  foreskin  of  the  penis  and  then  extends 
to  the  scrotum.  The  swelling  of  these  parts,  like  other  swellings  inci- 
dental to  the  disease,  is  due  to  back  pressure  of  the  lymph  on  the  parts, 
due  to  plugging  of  its  channel  which  has  been  occluded  by  the  mother 
worm.  The  chronic  state  of  this  lesion  leads  to  a  thickening  of  the 
skin  and  increase  of  connective  tissue  in  the  parts  involved.  This  is 
such  a  rare  condition  in  this  country  that  the  cause  of  the  lesions  may 
be  overlooked.  But,  as  a  rule,  by  careful  examination  of  the  blood 
both  by  day  and  night,  the  young  filaria  will  be  found. 

Several  times  each  year  cases  present  themselves  which  have  all  the 
ear-marks  of  true  elephantiasis,  even  to  the  skin  thickening  and  increase 
of  connective  tissue.  The  prepuce  is  often  markedly  swollen,  and  that 
part  at  the  frenum  stands  out  with  great  prominence.  The  most 
common  cause  of  these  cases  is  the  complete  destruction  of  the  inguinal 
glands,  generally  by  operative  removal,  or  rarely  by  inflammation.  In 
this  way  there  is  a  lymph  stasis. 

Strictures,  traumatism,  syphilis,  lymphangitis,  as  well  as  filth  under 
the  foreskin,  all  have  been  reported  as  causing  this  lesion. 

If  there  is  no  ulceration  or  infection  of  the  parts,  these  patients  have 
no  symptoms  referable  to  the  lesion,  and  their  general  health  is  not 
impaired.  Ulceration  and  infection  do  occur  rarely  in  very  marked 
cases.  The  size  of  the  organ  causes  a  great  deal  of  discomfort. 

Amputation,  or  excision,  including  when  possible  all  the  tissue 
involved,  has  proved  successful  in  some  instances. 

EPITHELIAL  CYSTS. 

In  clinics  which  are  attended  by  many  Jews,  cases  at  times  are  seen 
of  epithelial  cysts  of  the  remaining  foreskin.  These  are  probably  due 
to  faulty  method  of  circumcision.  From  the  same  cause,  cases  of 
tumor-like  formation  are  seen  where  there  has  been  poor  union  of  the 
skin,  and  sebaceous  glands  have  been  turned  under  and  in  this  position 
continue  to  secrete. 


TUMORS  OF  THE  PENIS  237 

The  secretions  of  the  sebaceous  glands  at  times  are  retained  and  cause 
small  but  oftentimes  numerous  tumors  of  the  penis.  These  are  situ- 
ated more  frequently  at  the  hairy  portion  of  the  organ. 

DERMOIDS  OF  THE  PENIS. 

True  congenital  dermoid  cysts  have  been  reported.  They  never 
attain  a  large  size,  but  contain  the  ordinary  elements  of  dermoid  cysts 
in  other  locations.  They  occur  mainly  near  the  raphe. 

TUMORS  OF  THE  PENIS. 

Papilloma  of  the  penis  is  rare  and  there  is  some  question  if  true  papil- 
loma  does  occur.  Waldeyer  reports  a  case  of  nineteen  years'  standing 
which  was  of  a  very  large  size.  The  tumor  involved  the  inner  and 
outer  foreskin,  as  well  as  the  shaft  of  the  penis.  He  made  the  diag- 
nosis of  a  true  papilloma,  as  its  elements  did  not  involve  the  connec- 
tive tissue. 

Fibromata  are  rare  and  of  little  importance.  The  cases  reported  are 
of  the  neurofibromata  type. 

Chondromata  are  rarely  seen  on  the  penis. 

Lipomata  may  occur  in  the  skin. 

So-called  venereal  warts  (condylomata  acuminata)  are  common. 
They  are  present  in  cases  of  congenital  phimosis  and  those  cases  in 
which  the  glands  at  the  corona  are  active  and  the  patient  does  not  keep 
the  parts  clean.  The  tumor  masses  are  true  epithelial  outgrowths. 
Treatment  is  excision.  These  wart-like  growths  are  prone  to  malignant 
degeneration. 

Carcinomata. — Carcinoma  of  the  penis  is  next  to  the  most  common 
skin  cancer.  It  occurs  usually  at  about  fifty,  rarely  before  forty  years 
of  age. 

Congenital  phimosis  is  an  important  etiological  factor.  The 
great  majority  of  reported  cases  have,  or  have  had,  phimosis.  Some 
cases  have  been  published  where  the  exciting  cause  was  a  wart,  or 
syphilitic  ulcer,  and  some  authorities  lay  stress  upon  trauma  or  inheri- 
tance. Although  the  infective  theory  has  been  advanced,  no  cases 
have  been  proved  where  cancer  of  the  penis  has  been  acquired  by 
intercourse  with  a  woman  having  carcinoma  of  the  cervix. 

The  classification  of  this  newgrowth  may  be  made  from  a  clinical 
or  pathological  stand-point.  Kiittner  divides  them  from  a  clinical 
stand-point  into  papillary  cancer,  carcinomatous  swelling,  and  tumors 
not  papillary,  but  adds  that  one  type  can  pass  into  the  other. 

Pathologically,  they  are  all  epitheliomata  and  can,  according  to  some 
pathologists,  arise  from  the  basic  or  squamous  cells.  This  naturally 
divides  cancer  of  the  penis  into  two  types.  This  theory  is  not  held  by 
many  authorities. 

The  majority  of  these  epitheliomata  occur  in  the  form  of  papillomata 
and  involve,  primarily,  the  glans  or  inner  leaf  of  the  foreskin.  Its 


238  DISEASES  OF   THE  PEXIS 

papillae  are  hard,  leaf-like  structures  in  contradistinction  to  the  fine 
villa?  seen  in  bladder  papillomata. 

The  peripheral  growth  soon  fills  the  space  between  the  glans  and  pre- 
puce, and  by  infiltrating  the  tissue  of  the  foreskin,  breaks  through  the 
preputial  sac  in  one  or  more  places.  The  glans  which  previously  has 
been  covered  by  the  infiltrated  foreskin  which  could  not  be  retracted, 
may,  after  this  perforation,  be  seen  again. 

It  is  rare,  even  in  cases  of  phimosis,  to  have  the  outer  leaf  of  the  fore- 
skin the  primary  seat  of  a  newgrowth.  Small  warty  growths  on  the 
glans  may  give  rise  to  neoplasm,  either  by  their  malignant  degene- 
ration or  carcinoma  may  develop  near  them.  The  foreskin  in  these 
cases  is  soon  distended  by  the  swollen  glans  and  cannot  be  retracted. 
This  is  due  to  the  disproportion  of  the  size  of  the  glans  and  the  fore- 
skin, while  in  those  cases  where  the  growths  occur  on  the  foreskin  the 
inability  to  retract  the  foreskin  is  due  to  the  infiltration  of  the  same. 
All  newgrowths  which  are  situated  under  the  foreskin  are  soft  and 
moist,  but  if  uncovered,  are  hard  and  dry.  The  papillary  branches 
spring  from  one  stem,  but  this  is  often  overlooked  on  account  of  the 
great  mass  of  these  branches.  Like  all  epitheliomata,  the  surface 
cells  tend  to  degenerate,  filling  the  interstices  with  a  white,  smegma- 
like,  foul-smelling  paste. 

These  tumors  may  grow  to  be  several  times  the  size  of  the  glans. 
The  growth  is  often  so  rapid  that  large  pieces  are  cut  off  from  their 
blood  supply,  die  and  fall  off. 

The  many  ulcerations  of  the  penis,  caused  by  the  infiltration  of  its 
tissue,  lead  to  fistula,  and  where  these  enter  the  urethra,  they  discharge 
urine. 

By  the  invasion  of  the  penis  by  the  growth  and  the  subsequent  death 
of  this  tissue  the  organ  wastes  away.  A  cauliflower  growth  perforated 
by  many  urine-delivering  fistula3,  connected  to  the  pubis  by  a  short 
stem,  the  remains  of  the  penis  shaft,  is  often  the  condition  of  the  patient 
when  he  presents  himself  for  treatment.  The  whole  penis  is  eventually 
sloughed  off  by  the  continuation  of  this  process.  The  pubis  and 
scrotum  may  be  involved.  The  patient  urinates  through  sinuses  in 
the  newgrowth,  which  connect  with  the  eroded  and  shortened  urethra. 

Kiittner  describes  a  form  of  carcinoma  which  he  says  is  rare.  It 
appears  as  an  ulcer  with  raised  edges,  either  on  the  glans  or  at  the  sulcus. 
The  growth  is  slow  at  first,  but  from  the  start  the  connective  tissue  of 
the  part  is  involved. 

The  other  form  described  by  him  he  claims  is  the  rarest  and  is  char- 
acterized by  a  grayish-white  discharge.  It  does  not  have  a  papillary 
structure  and  may  become  very  large.  The  tissue  of  the  tumor  has  a 
tendency  to  undergo  cystic  degeneration. 

Newgrowths  of  the  penis,  by  extension,  may  involve  the  scrotum, 
testicle,  prostate,  bladder,  rectum,  and  pelvic  cavity.  The  cavernous 
bodies  are  not  involved  early,  as  the  albuginea  offers  an  obstruction  to 
invasion,  but  when  involved  there  is  an  advance  of  the  growth  along 
the  cavernous  tissue.  The  inguinal  glands  are  the  first  lymph  glands 


TUMORS  OF  THE  PENIS  239 

to  be  involved,  then  the  retroperitoneal.  Metastases  are  common, 
although  they  take  place  late  in  the  disease. 

Symptoms. — Carcinoma  of  the  penis  begins  without  pain.  In  cases 
in  which  a  phimosis  exists  there  is  itching  of  the  parts,  and  as  ulceration 
takes  place  it  is  accompanied  by  a  discharge  which  may  be  profuse. 
Urination  may  be  impeded  either  by  the  newgrowth  obstructing  the 
outlet  of  the  foreskin,  or  by  ulceration  of  the  urethra.  As  the  condition 
advances,  erections  are  painful  and  later  disappear.  Pain,  when  present, 
is  due  usually  to  the  growth  invading  the  glans.  The  advance  of  the 
growth  is  slow,  as  a  rule,  often  a  year  elapses  before  the  patient  presents 
himself  for  treatment. 

Diagnosis. — The  diagnosis  is  difficult  to  make  in  early  cases  without 
microscopic  sections  of  the  tumor.  It  may  be  mistaken  for  a  condy- 
loma.  The  differential  points  are:  condyloma  tissue  is  soft  and  cancer 
is  hard;  the  attachment  of  condyloma  is  superficial,  while  cancer  is  deep. 

It  is  wise  to  make  microscopic  sections  of  the  tissue  in  all  cases. 
This  is  especially  easy  to  do,  as  most  cases  have  a  phimosis  which  must 
be  relieved  when  they  present  themselves  for  diagnosis. 

Treatment.— Treatment  is  amputation  with  radical  removal  of  the 
lymph  glands,  which  drain  the  field  of  operation. 

Sarcoma. — Sarcoma  of  the  penis  is  very  rare.  It  may  occur  as  a 
round  or  spindle-celled  tumor  which  infiltrates  the  tissue  of  the  penis. 

Myxomatous  types  are  very  rare,  while  the  melanosarcoma  are 
somewhat  more  common.  These  growths  develop  fast  and  the  lymph 
glands  are  soon  involved. 

Prognosis. — The  prognosis  is  very  bad  even  in  cases  of  early  operation. 

Diagnosis. — The  diagnosis  may  or  may  not  be  hard,  but  rarely  is  a 
case  diagnosticated  early  enough  for  a  cure. 


CHAPTER  VIII. 
GENITAL  ULCERS. 

BY  B.  C.  CORBUS,  M.D. 

Historical  Review. — The  Bible  is  the  most  ancient  as  well  as  most 
reliable  source  from  which  early  knowledge  in  regard  to  genital  ulcers 
can  be  obtained. 

The  plague  which  fell  upon  the  men  who  frequented  the  altars  of 
Baal  is  supposed  to  relate  to  ulcerations  of  the  penis,  while  the  lamenta- 
tions of  King  David  over  the  sharp  pains  in  his  bones  doubtless  refers 
to  the  effects  of  venereal  disease. 

Changes  in  the  throat  and  soft  palate  are  mentioned  by  St.  Paul 
in  his  epistle  to  the  Romans.  From  all  these  it  is  fair  to  infer  that 
genital  ulcers  with  their  accompanying  effects  existed  in  ancient  days. 

Hippocrates,  among  the  early  medical  writers,  speaks  of  ulcerations 
of  the  genital  organs,  of  tumors  of  the  groin,  of  ulcerations  of  the 
mouth,  and  of  extensive  pustular  eruptions  on  the  body. 

Later,  Celsus  describes  two  varieties  of  ulcers  on  the  penis,  which 
he  calls  "ulcera  sicca"  and  "ulcera  humida."  This  division  fits 
admirably  well  the  description  of  today — the  soft  chancre,  which 
suppurates  freely,  and  the  hard,  which  scarcely  suppurates  at  all. 

Celsus  also  describes  the  phagedena  which  may  invade  the  ulcers  at 
times. 

Aretaeus  describes  the  destruction  of  the  uvula  and  soft  palate. 

Cribasius,  like  Celsus,  divides  the  ulcers  into  dry  and  moist. 

Galen  speaks  of  ulcers  of  the  scrotum,  which  he  divides  into  two 
classes,  deep  and  superficial. 

Aretaeus  and  Paul  of  Aegina  both  make  mention  of  ulcerations  of 
different  kinds  that  develop  on  the  genital  organs. 

During  the  latter  part  of  the  fifteenth  century  (1496)  syphilis  was 
conveyed  by  sailors  of  Columbus  to  the  inhabitants  of  Seville  and 
Barcelona.  From  this  date  authentic  transmission  is  well  chronicled. 

For  want  of  a  name  the  disease  was  called  morbus  gallictus,  and  on 
account  of  the  primitive  character  of  domestic  relations  at  that  time, 
hardly  a  family  in  Spain  was  free  from  it  in  1494. 

The  cases  became  so  numerous  in  Seville  that  special  hospitals  were 
opened  to  cope  with  the  situation.  During  1494  the  whole  of  Italy 
was  infected,  progress  being  noted  from  town  to  town. 

In  1495  France,  Germany,  and  Switzerland  became  the  seats  of 
virulent  outbreaks. 

Holland  and  Greece  in  1496. 

England  and  Scotland  in  1497. 

Russia  and  Hungary  in  1499. 
(240) 


SYPHILIS  241 

In  1490  the  Decree  of  the  Parliament  of  Paris  required  all  infected 
persons  to  leave  the  city. 

In  Scotland,  during  Cromwell's  time  in  the  seventeenth  century. 

In  Norway  in  1720. 

In  Prussia  in  1757. 

In  Sweden  in  1762. 

In  Holland  in  1789. 

In  Uganda  (Africa)  in  1896. 

At  present  syphilis  exists  everywhere  in  the  world,  being  less  frequent 
in  the  rural  districts  and  most  frequent  in  the  large  cities. 

No  historical  sketch,  however  brief,  should  close  without  a  reference 
to  John  Hunter  and  Philippe  Ricord. 

In  1767  John  Hunter  inoculated  himself  on  the  prepuce  and  glans 
with  the  pus  from  a  virulent  gonorrhea,  and  produced  a  chancre  as 
well  as  constitutional  syphilis.  From  this  he  concluded  that  the 
secretion  from  a  case  of  gonorrhea  was  capable  of  producing  all  three 
diseases — gonorrhea,  chancroid,  and  syphilis. 

This  unfortunate  theory  was  not  disproved  <until  the  masterful 
Ricord,  by  his  careful  and  unbiased  observations  and  researches, 
showed  the  different  clinical  entities  of  gonorrhea,  syphilis  and  soft 
chancre. 

Classification. — Genital  ulcers  are  divided  into  two  classes: 

A.  Venereal  genital  ulcers. 

B.  Non- venereal  genital  ulcers. 

A.  Venereal  genital  ulcers,  which  may  be  classified  in  the  order  of 
their  importance,  as  follows: 

1.  Syphilis. 

(a)  Chancre. 

(6)  Ulcerated  papule. 

(c)  Gumma  or  chancre  redux. 

(d)  Esthiomene,  or  syphilitic  hypertrophy  of  the  vulva  with 

ulcerations. 

2.  Erosive  and  gangrenous  balanitis. 

3.  Chancroid. 

1.  SYPHILIS. 

(a)  Chancre. — Synonyms. — Primary  sclerosis;  initial  lesion  of 
syphilis;  hard  chancre;  Hunterian  chancre;  ulcus  durum. 

Definition. — A  true  syphilitic  chancre  may  be  defined  as  the  initial 
syphilitic  lesion  formed  at  the  point  of  inoculation,  and  the  first  known 
collection  of  Spirochseta  pallida. 

Etiology. — Predisposing  Causes. — (1)  Alcohol;  (2)  venereal  excesses; 
(3)  promiscuous  sexual  indulgence. 

Exciting  Causes. — The  Spirochseta  pallida  of  Schaudinn  and 
Hoffmann. 

Characteristic  Features  of  the  Spirochceta  pallida  as  Observed  with 
the  Dark-field  Condenser. — The  spirochetes  when  examined  with  the 

M  TJ     I — 16 


242 


(iKMTAL   ULCERS 


dark-field  condenser  are  much  more  typical  than  in  the  stained  speci- 
men, and  are  exact  duplicates  of  tissue  specimens  stained  by  the 
Levaditi  method.  The  most  characteristic  features  are: 

1.  Size. — They  vary  in  length  from  7  to  21  microns,  being  from  one 
to  three  times  the  diameter  of  a  red  blood  cell.     It  is  not  uncommon  to 
see  the  organism  longer  than  this,  but  on  account  of  the  difference  in 
the  motions  of  the  two  extremities  it  is  possible  that  these  long  forms 
are  composed  of  two  or  more  organisms. 

2.  Shape. — They  are  seen  to  consist  of  an  extremely  slender  thread 
closely  wound  in  a  corkscrew  or  spiral  spring  form,  the  windings 
being  very  acute.     In  the  fresh  specimens  the  windings  are  absolutely 
regular,  but  as  the  specimen  gets  older  the  organism  changes  form, 
the  most  frequent  change  being  an  obliteration  or  irregularity  of 
the  windings  in  the  central  portion.     This  is  a  very  common  appear- 
ance in  the  stained  preparations. 


FIG.  135. — Microphotograph.  Treponema  pallidum.  Dark-field  view  of  an  expressed 
specimen  (serum)  from  a  chancre.  X  1100.  These  are  identical  with  the  Levaditi- 
stained  spirochetes  as  shown  in  Fig.  144. 

3.  The  Ends. — These  are  sharp  and  terminate  on  the  periphery  of 
the  spiral  and  not  in  the  centre,  as  the  Spirochseta  buccalis  and  some 
of  the  other  forms  do.     This  peculiarity  of  the  ends  is  only  seen  when 
the  organism  rotates  on  its  long  axis. 

4.  Motiliiy. — When  the  specimen  is  freshly  prepared  the  organism 
is  very  active  and  possesses  the  following  motions:     (a)  A  rotation 
on  its  long  axis  in  either  direction;  this  motion  is  very  rapid,  but  not 
necessarily   accompanied  by   change   of   position;   as  the   specimen 
becomes  older  this  motion  grows  less.     (6)  It  progresses  from  place 
to  place,  but  not  so  rapidly  as  the  other  forms  of  spirochetes  commonly 
encountered,     (e)  They  have  a  bending  or  twisting  motion  which  is 
quite  quick  and  spasmodic.     This  bending  movement  increases  as  the 
specimen  ages  and  at  times  an  organism  is  seen  bent  in  the  form  of 
a  circle,  resembling  somewhat  a  crenated  red  blood  corpuscle.     It  is 
not  uncommon  to  find  two  organisms  joined  end  to  end. 


SYPHILIS  243 

Histology  and  Pathology. — The  abundant  discharge  from  a  fresh, 
specific  primary  lesion,  if  untreated,  contains  a  large  number  of 
Spirochseta  pallida,  but  if  seen  before  the  lesion  has  broken  down,  their 
demonstration  may  be  difficult,  unless  gentle  scarification  and  cupping 
are  practised. 

The  spirochetes  are  irregularly  distributed  in  the  foci,  which  accounts 
for  failure  at  times  to  demonstrate  the  organism  after  the  Levaditi 
method.  This  more  or  less  irregular  distribution  of  the  spirochetes 
occurs  more  particularly  in  fresh  lesions.  As  the  spirochetes  are 
responsible  for  the  periarteritis  and  endarteritis,  they  are  found  most 
abundantly  in  tissues  immediately  surrounding  the 'bloodvessels,  in 
the  walls  of  the  vessels  themselves,  in  the  lymph  spaces,  and  in  the 
Malpighian  bodies  (Figs.  136  and  137). 


FIG.  136.— Chancre  of  penis  (low  power).  Shows  moderately  advanced  lesion,  blood- 
vessels much  increased,  with  walls  thickened.  Marked  proliferation  of  endothehal 
leukocytes  into  walls  of  vessels,  causing  endarteritis.  In  the  connective-tissue  stroma 
exudate  is  marked,  consisting  of  polymorphonuelear  leukocytes  and  plasma  cells. 
(Author's  case.) 

The  intitial  sclerosis  shows  in  the  early  stages  a  lymphocyte  and 
plasma-cell  infiltration  around  the  blood  and  lymph  vessels  in  the 
depth  of  the  cutis  and  the  papillary  bodies.  Gradually  the  lumen  of 
the  bloodvessels  becomes  widely  distended,  there  is  swelling  and 
proliferation  of  the  endothelium  and  formation  of  new  capillaries. 
Inflammatory  changes  and  proliferation  occur  in  the  tissues  surround- 
ing the  vessels.  This  congestion  and  proliferation  of  the  capillaries 
increases,  the  vessels  become  thrombosed,  resulting  in  destruction  of 
the  vessels  and  a  degeneration  of  the  cellular  exudate.  Gradually 


244 


the  epithelium  covering  the  lesion  shrinks  and  becomes  necrotic,  while 
the  papillae  in  the  vicinity  of  the  erosion  become  enlarged  and  the 
infiltration  extends  out  over  the  ulcer  onto  the  surrounding  epithelium, 
both  laterally  and  deeply;  later  more  extensive  inflammatory  changes 
result  in  and  about  the  arteries,  veins,  and  lymph  vessels.  There  is  an 
increase  of  yellow  elastic  fibers. 

It  is  this  condition  which  constitutes  the  specific  induration,  and 
the  amount  of  induration  will  depend  on  the  depth  of  the  vessels  which 
are  affected. 

Incubation. — The  period  of  incubation  is  from  ten  to  twenty-eight 
days  (exceptional  cases  longer);  most  frequently  from  fourteen  to 
twentv-one  da  vs. 


FIG.  137. — Chancre  of  penis  (high  po\vrr  .     Slm\vs  wall  of  bloodvessel  infiltrated  with 
many  endothelial  leukocytes. 

Classification:  A.  Anatomical.     B.  Clinical. 

A.  ANATOMICAL  CLASSIFICATION. — The  location  of  the  primary  lesion 
depends  on  the  site  of  contact  and  inoculation  and  may  be  anywhere 
on  the  genitals,  i.  e.,  scrotum,  labium,  urethra,  glans  penis,  etc. 

B.  CLINICAL  CLASSIFICATION. 

1.  Chancrous  erosions. 

2.  Chancrous  ulceration,  superficial  and  deep. 

3.  Indurated  papule. 

A  chancre  is  not  auto-inoculable  after  ten  days,  but  may  be  so 
before.  It  is,  as  a  rule,  single  (single  point  of  contact)  but  may  be 
double  or  multiple  (multiple  point  of  contact).  The  author  has  had  the 
opportunity  of  observing  a  case  in  which  there  were  five  lesions  arranged 


SYPHILIS  245 

around  the  glans  penis,  somewhat  resembling  a  collar,  in  each  of  which 
Spirochseta  pallida  were  demonstrated. 

1.  Chancrous    Erosions.— After    variable    periods    of    incubation, 
depending  on  the  virulency  of  the  spirochete  and  the  receptiveness  of 
the  host,  the  chancre  manifests  itself.     At  first  there  is  a  hyperemic 
area;  this  later  becomes  a  superficial  papule  and  still  later,  through  its 
inherent  pathology,  slight  traumatism  and  mild  secondary  infection 
becomes  a  superficial  erosion,  thus  marking  the  beginning  of  the 
chancre.     A  common  form  seen  is  a  " small  abrasion,"  and  on  account 
of  its  insignificant  appearance  is  most  frequently  permitted  to  go 
undiagnosed  for  some  time. 

Induration,  as  a  rule,  is  very  slight  or  entirely  absent.  Later  this 
erosion  enlarges  and  assumes  a  more  deeply  red  appearance  and  may 
pass  into  the  following: 

2.  Chancrous    I'keration,   Superficial  and    Deep. — The  superficial 
erosion  rapidly  extends  in  breadth  and  depth.     Induration  is  the  rule 
and  may  be  marked,  but  is  always  superficial  at  first.    The  ulcers  are 
dusky  red,  circular  and  slightly  cup-shaped,  with  smooth,  slanting 
walls.     A  false  membrane  may  be  adherent  over  the  lesion,  and  slight 
irritation  causes  an  abundant  exudation  of  serum.     Later  the  indura- 
tion extends  deeper,  the  ulcer  destroying  the  true  skin  as  well  as  the 
tissue  beneath  it. 

3.  Indurated  Papule. — In  this  form  the  lesion  occurs  where  the 
integument  is  thick;  it  retains  its  papular  form  and  may  attain  large 
dimensions,  0.5  to  2.5  cm.  in  diameter;  its  surface  remains  intact,  and, 
as  a  rule,  there  is  little  excretion. 

Morton9  says :  "  The  forms  of  the  chancres  differ,  depending  on  the 
anatomical  part  on  which  they  are  located  and  also  on  the  course  and 
situation  of  the  bloodvessels. 

"\Yhen  they  run  horizontally  and  near  to  the  surface,  a  thin,  flat 
layer  of  infiltration  occurs  under  the  skin,  which  is  called  parchment 
induration.  On  the  other  hand,  when  the  bloodvessels  dip  down  deeply 
into  the  tissues,  the  induration  is  extensive  and  deep  and  is  called 
Huntcrian  induration"  (Figs.  138  and  139). 

For  example,  inside  the  prepuce  the  parchment  chancre  often 
occurs;  in  the  sulcus  coronarius,  a  heavy  mass  of  infiltration  takes 
place,  forming  a  Hunteriaii  chancre.  In  the  frenulum  a  thick  cord 
occurs,  and  on  the  glans  a  flat  erosion. 

Pain. — All  primary  lesions  are  characterized  by  their  lack  of  dis- 
comfort, both  local  and  constitutional,  unless  complicated  by  a  mixed 
infection  or  situated  where  there  is  continually  a  change  of  its  base 
(urethral  chancre).  Inflammation,  except  over  the  site,  is  usually 
slight,  the  patient's  attention  being  first  drawn  to  the  condition  by 
stinging  and  burning,  as  if  he  had  been  bitten  by  a  fly  or  some  small 
insect. 

In  careless  individuals  and  those  who  are  slovenly  in  their  toilet,  a 
chancre  may  attain  large  proportions  before  it  is  noticed. 

In  most  chancres  an  abundant  exudation  of  serum  can  easily  be  pro- 


246 


GENITAL   ULCERS 


FIG.   138. — Typical  Hunterian  chancre.     (Author's  case.) 


FIG.  139. — Same  as  Fig.  138,  twelve  days  after  injection  of  0.5  gm.  salvarsan. 
(Author's  case.) 


SYPHILIS  247 

voked  by  gentle  irritation  or  cupping,  this  being  due  to  the  abundant 
vascular  supply. 

Diagnosis. — So  rapid  and  exact  have  become  our  methods  of  diag- 
nosis in  primary  lesions  that  the  physician  who  fails  to  avail  himself 
of  these  accurate  and  specific  diagnostic  methods  should  be  held 
responsible. 

Many  physicians,  seeing  a  lesion  for  the  first  time,  thoughtlessly 
prescribe  a  little  dusting  powder,  while  all  the  time  the  organisms 
of  syphilis  are  multiplying,  and  daily  the  possibility  of  a  speedy  cure 
lessens. 

A  favorite  dusting  powder  for  genital  ulcers  is  calomel.  This 
dusted  on  a  lesion  temporarily  destroys  the  spirochetes  in  situ  and 
it  may  be  several  days  before  all  the  powder  can  be  removed;  in 
the  meantime  the  disease  slowly  progresses.  Occasionally  puncture 
of  the  inguinal  glands  will  reveal  the  organism,  but  this  is  not  an 
easy  procedure. 

The  safest  method  for  the  patient  and  his  physician  is  to  treat  all 
ulcers  in  the  light  of  a  specific  origin — apply  no  treatment  whatever 
and  permit  no  mutilation  in  the  way  of  cauterization  until  it  has  been 
thoroughly  demonstrated  by  a  careful  laboratory  worker  that  syphilis 
does  or  does  not  exist.  The  removal  of  sufficient  clothing  to  permit  a 
thorough  examination  of  the  body  should  be  insisted  on.  Often  the 
clinical  picture  at  the  secondary  period  is  so  pronounced  that  added 
laboratory  findings  are  only  confirmatory;  however,  in  the  primary 
stage,  without  laboratory  confirmation,  one  should  not  feel  safe  in 
making  a  positive  diagnosis. 

The  Dark-ground  Illuminator. — This  method  was  described  by  the 
Rev.  J.  B.  Read  in  1837.  He  used  practically  the  same  apparatus  that 
we  are  using  today.  Read  described  his  method  just  at  the  time  that 
Professor  Abbe  brought  out  his  well-known  substage  condenser,  and 
in  the  excitement  over  Professor  Abbe's  invention,  the  dark-ground 
illuminator  was  forgotten  until  rediscovered  by  Reichert,  the  micro- 
scope manufacturer  of  Vienna,  in  1907. 

The  advantage  of  this  method  depends  on  the  illumination,  the 
principle  of  which  is  the  same  as  that  causing  dust  particles  to  become 
visible  when  passing  through  a  beam  of  sunlight. 

The  apparatus  of  Reichert  consists  of  a  metallic  plate,  having  a 
hole  in  the  centre,  above  which  is  fitted  a  piece  of  glass  having  a  circu- 
lar excavation  on  its  under  surface.  The  sides  of  this  excavation  are 
ground  at  a  certain  angle  and  silvered.  By  means  of  a  revolving  disk, 
different-sized  diaphragms  are  used  to  cover  the  central  part  of  the 
excavated  area,  so  that  when  the  light  is  reflected  up  from  the  plane 
mirror  of  the  microscope,  only  the  marginal  rays  reach  the  glass  plate. 
These  impinge  on,  and  are  reflected  by,  the  silvered  sides  of  the  excava- 
tion to  a  central  point  1  mm.  above  the  surface  of  the  glass  plate. 
Any  solid  body  here  will  intercept  these  rays  and  appear  as  luminous 
objects  on  a  dark  ground.  By  this  method  it  is  possible  to  see  the 
particles  of  colloidal  substances  in  their  solutions  (Figs.  140  and  141). 


248 


GENITAL    f'LCEKS 


The  He/chert  Instrument. — A  form  of  dark-ground  illuminator  is 
now  manufactured  by  most  of  the  microscope  makers,  but  the  Reichert 
instrument  is  superior  to  others  for  the  following  reasons: 


FIG.  140. — The  Reichert  apparatus  for  "dark-ground"  illumination,  to  he  attached  to 

the  microscope  statrc. 


FIG.  141.— Nernst  lamp.     For  use  with  the  Reichert  dark-ground  illuminator. 

1.  It  can  be  used  on  any  kind  of  microscope. 

2.  The  light  may  be  varied  at  will,  by  means  of  the  revolving 
diaphragm. 

3.  It  is  possible  to  change  from  the  dark-ground  method  to  the 


SVP///A7.S-  249 

ordinary  method  of  transmitted  light  merely  by  revolving  the  dia- 
phragm. 

The  method  of  using  the  apparatus  is  as  folio 

The  Abbe  condenser  is  removed.  A  strong  light  is  necessary;  one 
may  use  the  sun,  an  arc  light,  a  Xernst  lamp,  or  an  inverted  Welsbach. 
^  ith  the  in  verted  Welsbach,  a  six-inch  condenser  lens  is  necessary,  or 
a  large  glass  globe  filled  with  water  serves  the  same  purpose.  The 
illuminator  is  placed  on  the  stage  of  the  microscope,  and  by  means  of 
the  low  power  the  circle  which  is  etched  on  the  glass  plate  is  brought 
into  the  centre  of  the  field  and  the  apparatus  fixed  in  this  position  by 
means  of  the  clips  of  the  microscope.  A  drop  of  immersion  oil,  free 
from  air  bubbles,  is  placed  on  the  centre  and  the  prepared  slide  put  in 
place,  great  care  being  taken  to  avoid  the  formation  of  air  bubbles. 
When  the  preparation  is  examined  with  the  low  power,  if  the  light  is 
placed  right  and  the  apparatus  centred,  a  bright  central  point  will  be 
observed.  The  high  power  is  now  turned  on  and  the  field  is  seen  to 
be  dark,  with  luminous  points  and  bodies. 

Preparation  of  the  Materials. — The  method  of  preparing  the  speci- 
men is  very  important.  The  slide  must  be  1  mm.  thick,  and  both 
slide  and  cover-glass  must  be  perfectly  clean  and  well  polished,  as  any 
turbidity  or  scratches  disperse  the  light  and  cause  annoying  halos, 
which  prevent  the  dark-ground  effect  and  interfere  with  the  examina- 
tion. Air  bubbles  in  the  specimen  also  cause  these  disturbing  effects. 
The  specimen  must  be  as  thin  as  possible.  The  observation  is  best 
made  with  a  dry  system.  The  author  uses  a  Leitz  |-inch  objective 
and  a  Xo.  5  ocular.  An  oil  immersion  can  be  used;  in  this  case,  how- 
ever, it  is  necessary  to  diminish  the  aperture  of  the  objective  by 
inserting  a  truncated  cone  back  of  the  front  lens  of  the  objective.  This 
cuts  out  the  diverging  rays  of  light,  which  otherwise  would  flood  the 
field.  For  diagnostic  purposes  it  is  seldom  necessary  to  use  the  oil 
immersion. 

M rt hod  of  Obtaining  the  Material. — For  chancre  (Fig.  142)  it  is 
sufficient  to  clean  the  lesions  thoroughly  with  warm  water.  They 
are  then  irritated  by  being  rubbed  vigorously  with  a  piece  of  cotton 
wrapped  on  a  probe,  thus  causing  an  abundant  exudation  of  serum. 
This  is  collected  by  means  of  a  capillary  pipette  as  shown  in  Fig.  142. 
A  small  drop  of  this  is  placed  on  a  cover  glass,  which  is  now  carefully 
inverted  on  the  slide  as  in  making  a  fresh  blood  preparation.  It  is 
well  not  to  have  much  admixture  of  blood,  as  the  blood  cells  interfere 
somewhat  with  the  observation. 

On  looking  at  a  specimen  containing  serum  from  a  chancre,  numerous 
small,  round,  luminous  bodies  are  seen,  which  have  a  very  active 
Brownian  movement.  These  particles  of  albumin  are  probably  identi- 
cal with  the  blood  dust  of  Miiller.  If  the  cleansing  has  not  been 
thorough,  various  forms  of  bacteria  are  often  seen,  the  cocci  looking 
like  pearls.  The  leukocytes  are  seen  as  a  mass  of  white  granules 
surrounding  the  dark  nucleus,  the  various  forms  being  easily  differ- 
entiated. The  ameboid  movement  and  the  granules  in  an  active 


250 


GENITAL   ULCERS 


Brownian  motion  are  frequently  seen.     The  red  corpuscles  show  as  a 
luminous  ring  surrounding  a  central  pale  reddish  zone. 

Stain  ui(/  Methods. — Schaudinn  and  Hoffmann's  many  attempts  at 
staining  the  Spirochseta  pallida  did  not  prove  successful,  until  finally 


FIG.  142. — Method  of  collecting  serum  from  suspected  lesion  by  capillary  attraction. 

they  succeeded  with  Giemsa's  solution.  It  would  be  out  of  place  in 
such  a  work  as  this  to  give  a  detailed  account  of  all  the  methods  which 
have  been  developed  for  this  purpose,  and  mention  will  be  made  only 
of  those  of  most  practical  value. 

Giemsa's  Ordinary  Method. — (Fig.  143): 


FIG.   143. — Microphotograph   of   Treponema   pallidum   from    chancre. 

X  1100.     (Author's  case.) 


Giemsa   stain. 


1.  Fix  the  film  for  five  minutes  in  absolute  alcohol. 

2.  Dilute  the  stain  in  tap-water  or  distilled  water  to  which  a  drop 
or  two  of  a  1  to  20,000  solution  of  sodium  carbonate  has  been  added; 
use  about  30  drops  of  the  stain  to  every  20  c.c.  of  water. 


SYPHILIS 


251 


3.  Pour  the  stain  into  a  shallow  dish  and  place  the  preparation  face 
downward  in  it.     The  slide  is -prevented  from  touching  the  bottom 
of  the  dish  by  two  pieces  of  glass  tubing. 

4.  Staining  is  complete  in  from  one  to  twelve  hours. 

5.  Wash  gently  in  water,  and  dry. 
Giemsa's  Rapid  Method: 

1.  Fix  as  above. 

2.  Dilute  the  stain  with  an  equal  volume  of  water  containing  1  to 
20,000  solution  of  sodium  carbonate. 

3.  Pour  the  stain  onto  the  film,  and  heat  the  slide  gently  over  a 
Bunsen  burner  until  vapor  is  given  off.    Replace  the  stain  with  a  fresh 
quantity  and  heat  again.     This  process  should  be  repeated  three  or 
four  times,  the  final  application  lasting  two  minutes. 

4».  Wash  in  water,  and  dry. 


FIG.  144. — Microphotograph.      Spirochetes   from   the   liver   of   a    congenitally   luetic 
infant,  stained  after  Levaditi's  method.     X  1200.     (Author's  case.) 

Levaditi's  Method  (Fig.  144). — This  method  is  really  a  modification 
of  that  used  by  Ramon  y  Cajal  for  demonstrating  nerve  fibrils,  and 
owing  to  its  freedom  from  precipitates  in  comparison  with  the  other 
silver  stains,  is  now  almost  universally  employed  to  demonstrate 
spirochetes  in  the  tissues. 

The  method  is  as  follows: 

1.  Fix  fragments  of  the  tissue,  not  thicker  than  1  or  2  mm.,  in  a  10 
per  cent,  solution  of  formalin  for  twrenty-four  hours. 

2.  Wash  in  water  and  transfer  to  alcohol  (96  per  cent.)  for  twenty- 
four  hours. 


252  GENITAL   ULCERS 

3.  Wash  in  distilled  water  until  the  pieces  of  tissue  fall  to  the  bottom 
of  the  jar. 

4.  Impregnate  from  three  to  five  days  at  oS°  (".  in  a  2  per  cent,  solu- 
tion of  silver  nitrate  in  the  dark. 

5.  Wash  in  water  and  reduce  overnight  at  the  temperature  of  the 
room  in  the  following  bath: 

Acid  pyrogallic 4  gm. 

Formalin 5  c.c. 

Water,  distilled 91  c.c. 

6.  Wash  in  water,  dehydrate,  and  embed  in  paraffin  in  the  usual 
way. 

7.  Cut  the  sections  not  thicker  than  5  microns  and  mount  in  Canada 
balsam.     No  further  staining  is  required,  though  Levaditi  has  recom- 
mended counter-staining  with  toluidin  blue,  neutral  red  or  Giemsa's 
solution. 

Levaditi  and  Mamouelians  Rapid  Silver  Method. — Levaditi  recom- 
mends this  method  for  staining  tissues  which  have  been  removed 
during  life,  or  immediately  after  death. 

1.  The  tissue  is  cut  and  fixed  as  in  the  previous  method. 

2.  Impregnate  in  the  following  solution  for  twelve  hours  at  room 
temperature,  and  then  for  five  or  six  hours  at  55°  C.  : 

Silver  nitrate  solution,  1  per  cent 90  c.c. 

Pyridine 10  c.c. 

3.  WTash  in  water  and  reduce  in  the  following  solution  overnight: 

Pyridine 17  c.c. 

Acetone 10  c.c. 

Acid  pyrogallic  (4  per  cent.) 90  c.c. 

4.  Dehydrate,  and  embed  in  paraffin  in  the  usual  way. 

5.  Cut  sections  not  thicker  than  5'microns. 

The  India-ink  method  of  Burri,  while  recommended  as  short  and 
reliable,  is  a  poor  makeshift.  The  demonstration  of  the  spirochetes  is 
complicated  by  too  many  artefacts  (Fig.  145). 

Although  a  wonderful  advancement  has  been  made  in  the  treatment 
of  syphilis,  comparatively  few  realize  the  role  that  the  early  diagnosis 
plays  in  the  cure  of  the  patient. 

Many  staining  methods  for  the  detection  of  the  spirochete  have  been 
recommended  as  short  and  reliable,  but  none  has  as  many  advantages 
as  the  dark-field  condenser,  as  here  the  demonstration  of  the  living 
spirochete  is  characteristic  and  distinct.  From  an  experience  dating 
from  the  year  1908,  consisting  of  many  hundreds  of  examinations,  the 
author  considers  that  the  one  and  only  method  for  use  is  the  dark- 
field  condenser.  The  advantages  of  this  method  depend  on  the 
illumination,  which  is  greatly  facilitated  by  the  new  Nernst  lamp. 
This  style  of  lamp  has  an  advantage  over  the  arc  light,  in  that  it  gives 


SYPHILIS 


253 


a  continuous,  strong  light,  with  no  breaking  or  closing  of  the  circuit 
or  burning  out  of  carbons. 

Noguchi's  method  of  snipping  out  a  small  piece  of  the  lesion  and 
macerating  it  with  salt  solution  in  a  mortar  offers  an  excellent  way  of 
obtaining  the  organism  in  large  quantities,  for  in  this  manner  they  are 
expressed  from  the  lesion  and  appear  abundantly. 

The  universal  procedure  of  making  a  smear  from  a  lesion,  just  as  one 
would  do  in  making  an  ordinary  pus  smear,  should  be  emphatically 
condemned,  as  it  is  absolutely  impossible  for  the  laboratory  in  this 
way  to  do  itself  justice. 

The  Wassermann  Reaction.— Frequently  the  Wassermann  reaction 
is  resorted  to  as  a  final  word  in  diagnosis.  It  must  be  distinctly 
understood  that  the  Wassermann  test  cannot  be  relied  on  at  the  period 
of  primary  invasion;  that  the  reaction  is  positive  in  direct  proportion 
to  the  time  of  the  presence  of  the  primary  lesion;  that  the  reaction 
is  nearly  always  negative  until  about  three  weeks  after  the  first  appear- 
ance of  the  sore,  and  after  that  period  it  is  invariably  positive. 


FIG.   145. — Microphotograph  of  Treponema   pallidum   from  chancre.      Burri's   India- 
ink  method.      X  1600.     (Author's  case.) 

However,  during  the  presence  of  the  primary  lesion  there  are  two 
things  that  we  wish  to  know.  They  are: 

(1)  The  result  of  the  Wassermann  reaction  on  the  blood,  as  a 
biological  guide  to  future  treatment;  and  if  this  should  prove  positive, 
(2)  the  result  of  the  spinal  fluid  examination  as  a  control  on  future 
complications  of  the  nervous  system. 

1.  Wassermann  Reaction  on  the  Blood. — For  example,  a  patient 
presents  himself  for  examination.  Diagnosis  is  made  by  finding  the 
spirochete  in  the  primary  lesion.  Assume  that  the  Wassermann 
examination  is  negative.  This  shows  that  the  system  is  not  involved 
to  any  great  extent  and  the  possibilities  of  a  speedy  cure  are  good. 
On  the  other  hand,  take  a  similar  case  in  which  the  diagnosis  is  made 
by  finding  the  spirochetes  in  the  primary  lesion,  but  with  the  Wasser- 
mann examination  positive.  This  shows  a  considerable  systemic 
invasion  and  is  not  so  favorable  for  a  speedy  cure. 


254  GENITAL   ULCERS 

It  is  not  generally  recognized  that  the  consumption  of  even  small 
quantities  of  alcohol,  if  taken  from  one  to  seven  days  before  the 
Wassermann  is  made,  tend  to  influence  the  test  by  producing  a  false 
negative  reaction.  Attention  was  first  called  to  this  by  Craig  and 
Nichols,2  of  the  United  States  Army,  and  since  then  it  has  been  verified 
by  serologists  generally. 

2.  Spinal  Fluid  Examination. — During  the  past  two  years,  numerous 
observers,  both  in  this  country  and  abroad,  have  called  attention  to  the 
fact  that  the  nervous  system  is  already  involved  in  early  syphilis,  a 
thing  almost  undreamed  of  before  this  time.  This  involvement  seems 
to  be  due  to  a  selective  type  of  spirochete,  and  it  becomes  our  duty  to 
puncture  the  spinal  canal  in  those  cases  which  show  a  strong  positive 
Wassermann,  if  we  wish  to  control  the  situation  here  as  well  as  in  the 
blood  stream. 

The  spinal  fluid  examination  consists  of  the  following: 

1.  Wassermann  reaction. 

2.  Cell  count. 

3.  Globulin  reaction. 

(a)  Xoguchi. 

(b)  Xonne-Apelt. 

4.  Pressure. 

Technic. — Lumbar  puncture  is  always  performed  best  with  the 
patient  lying  on  his  side.  Inasmuch  as  5  c.c.  of  fluid  are  essential 
for  a  proper  examination,  it  is  advisable  to  perform  the  puncture  only 
in  a  hospital.  During  the  withdrawal  of  the  fluid,  the  patient  should 
lie  absolutely  flat  (without  pillow)  and  this  position  should  be  main- 
tained for  twenty-four  hours,  with  the  addition  of  the  elevation  of 
the  foot  of  the  bed  after  the  patient  has  been  removed  from  the 
operating  room. 

1.  The  Wassermann  Reaction.— Of  all  the  tests,  the  Wassermann 
reaction  on  the  spinal  fluid  is  the  most  reliable.     Frequently,  however, 
an  error  has  been  made  in  taking  too  small  a  quantity  of  this  fluid;  at 
least  seven  times  the  quantity  that  is  required  for  the  blood  Wasser- 
mann is  absolutely  essential  for  accurate  results. 

2.  Cell  Count. — The  following  standard  of  Dreyfus,4  based  on  750 
punctures,  is  recommended  by  Ellis  and  Swift,6  of  the  Rockefeller 
Hospital : 

1  to    5  cells  per  c.mm. — Normal. 
6  to    9  cells  per  c.mm. — Doubtful,  border  cases. 
10  to  20  cells  per  c.mm. — Slight  lymphocytosis. 
21  to  50  cells  per  c.mm. — Moderate. 
Over  50  cells  per  c.mm. — Marked. 

Technic  of  Leukocyte  Count  of  Spinal  Fluid. — The  apparatus 
employed  is  the  Turck.  The  spinal  fluid  to  be  tested  is  thoroughly 
shaken.  Draw  up  in  the  white-cell  counting  pipette  10  per  cent, 
acetic  acid  to  the  mark  I,  then  the  spinal  fluid  to  the  mark  II.  This 
gives  an  employment  of  9  parts  of  spinal  fluid  to  10  parts  of  the  mixture, 
or  y9^-  of  the  mixture  is  spinal  fluid.  Blow  out  the  first  few  drops  of  the 


SYPHILIS  255 

solution  from  the  pipette  and  then  place  on  the  chamber  just  sufficient 
fluid  so  that  with  pressure  of  the  cover-glass  Newton's  rings  appear  at 
the  four  corners.  Count  the  cells  in  the  w;hole  ruled  area.  This  space 
contains  f^  c.mm.  of  fluid.  The  mixture  is  y9^  spinal  fluid  and  T\j- 
diluting  fluid.  Therefore  the  number  of  cells  counted  x  V~  x  -^  =  the 
number  of  cells  per  c.mm.  For  example,  the  9  sq.  mm.  contains  40 
cells.  40  x  -V"  x  T9-  =  49.  If  cells  are  so  numerous  as  to  cause  cloud- 
ing, the  spinal  fluid  must  be  diluted  as  for  a  leukocyte  count  of  the 
blood. 

3.  Globulin. — This  test  may  be  made  after  the  method  of  Noguchi 
or  the  method  of  Nonne-Apelt. 

Technic  of  the  Noguchi  Butyric  Acid  Test. — To  0.2  c.c.  of  spinal  fluid 
add  0.5  c.c.  of  10  per  cent,  butyric  acid  in  physiological  salt  solution. 
Boil  carefully  over  a  small  flame  for  one  minute  and  add  quickly  0.1 
c.c.  of  normal  sodium  hydrate  and  boil  again  for  a  few  seconds.  In  the 
presence  of  excess  globulin,  a  precipitate  forms  of  varying  intensity, 
depending  on  the  amount  of  globulin  present.  A  cloud  may  appear 
in  normal  fluid. 

Technic  of  the  Ross- Jones  Modification  of  the  Nonne  Test. — Float  on 
top  of  about  0.5  or  1  c.c.  of  supersaturated  (by  heat)  ammonium  sul- 
phate solution,  about  one-half  the  quantity  of  spinal  fluid.  In  the 
presence  of  excess  globulin  a  white  ring  forms.  In  case  of  small 
quantity  of  globulin,  if  the  ring  is  either  absent  or  indistinct,  shaking 
the  tube  will  cause  the  clouding  to  become  prominent. 

4.  Pressure. — Pressure  is  estimated  by  allowing  the  fluid  to  run  into 
a  graduated  manometer  tube  with  a  bore  3  mm.  in  diameter  and 
reading  the  height  to  which  the  fluid  rises.     This  figure  is  only  relative. 

Necessity  for  Spinal  Fluid  Examination  in  Syphilis. — Ever  since  the 
discovery  of  Noguchi11  that  the  cerebrospinal  fluid  in  paresis,  cerebro- 
spinal  syphilis  and  tabes  contains  live  active  spirochetes  which  are 
capable  of  being  transmitted  to  animals,  a  new  light  has  been  thrown 
upon  subarachnoid  involvement.  How  this  involvement  takes  place 
is  not  exactly  known;  whether  the  spirochetes  are  capable  of  passing 
through  the  choroid  plexus,  or  advancing  along  the  lymphatics  that 
accompany  the  nerves,  future  investigation  will  have  to  determine. 

There  is  little  doubt,  as  Mott10  has  already  shown,  that  there  is  a 
selective  type  of  organism  that  has  a  predilection  for  the  nervous 
system. 

Differential  Diagnosis. — Notwithstanding  the  many  newer  diagnostic 
methods  that  are  in  vogue,  clinical  symptoms  should  be  carefully  noted 
and  the  laboratory  carefully  checked  up,  especially  since  there  are  so 
many  laboratories  whose  reports  are  conflicting. 

Scabies. — Occasionally  there  occurs  on  the  glans  penis  an  isolated 
area  of  scabies.  If  the  surgeon  will  take  the  trouble  to  have  the 
patient  remove  his  clothing,  as  a  rule,  numerous  evidences  of  this 
parasitic  affection  can  be  found  on  other  parts  of  the  body.  There  is 
no  period  of  incubation  and  microscopic  examination  for  spirochetes 
is  negative.  The  condition  remains  as  a  papule  with  no  inguinal 


256  GEXITAL    ULCERS 

adenopathy;  itching  is  a  prominent  symptom,  especially  after  retiring 
at  night. 

(See  end  of  chapter  for  tabulated  points  of  diagnosis  of  Chancre, 
Chancroid,  Herpes  Zoster  and  Erosive  and  Gangrenous  Balanitis.) 

Prognosis. — The  prognosis  in  all  uncomplicated  luetic  lesions  is 
excellent,  but  to  say  that  every  case  with  its  attending  systemic 
infection  can  be  cured  is  just  as  foolish  as  to  say  that  no  case  can  be 
cured.  The  curability  of  syphilis  depends  on  making  a  prompt  diag- 
nosis, for  the  earlier  a  case  comes  under  observation,  the  easier  it  is  to 
effect  a  cure.  That  the  biological  method  offers  the  best  means  of 
controlling  the  treatment  of  the  disease  there  can  be  no  question. 
Unfortunately,  the  tendency  is  to  give  too  little  treatment. 

Prophylaxis. — The  use  of  a  condom  during  sexual  relations  is  perhaps 
the  best  safeguard  against  infection.  Metchnikoff 's  calomel  ointment 
(calomel  20,  lanolin  40),  if  used  up  to  within  two  hours  after  exposure, 
has  proved  a  reliable  preventative  in  the  army  and  navy.  As  reliable 
substitutes,  mercurettes  (Parke,  Davis  &  Co.)  and  50  per  cent,  mercury 
ointment  may  be  used.  Recently,  Schereschewsky13  has  proved  experi- 
mentally upon  apes  that  40  per  cent,  quinine  is  safe  and  efficient,  if 
applied  after  the  same  method  as  the  mercury  ointment. 

As  the  primary  lesion  is  only  a  local  manifestation  of  a  general 
infection,  the  treatment  may  be  divided  into  local  and  systemic. 

Local  Treatment. — Xo  treatment,  either  general  or  local,  should  be 
instituted  before  a  positive  diagnosis  is  made. 

Excision  of  the  Chancre. — As  the  initial  lesion  of  syphilis  is  the  first- 
known  collection  of  spirochetes,  Lukasiewicz,  Jadassohn,7  and  others 
declare  that  if  excision  of  the  chancre  is  done  before  the  period  of  second 
incubation,  the  infection  is  attenuated.  It  is  reasonable  to  suppose 
that  if  we  have  a  large  area  that  is  constantly  feeding  the  system  with 
infecting  organisms,  that  area  should  be  removed,  especially  since 
its  removal  does  not  entail  any  serious  effects  on  the  patient.  When- 
ever it  is  at  all  possible,  without  undue  loss  of  tissue,  the  chancre 
should  be  excised.  In  those  cases  in  which  the  lesion  is  so  situated 
that  its  removal  would  cause  extensive  destruction  of  tissue,  one  should 
be  satisfied  with  thorough  cauterization  and  curettement  and  the  free 
use  of  calomel.  In  cases  in  which  either  excision  or  curettement  would 
cause  a  troublesome  scar  (urethral  chancre),  calomel  dusting  powder 
should  be  used. 

General  Treatment. — As  soon  as  the  diagnosis  of  a  specific  infection 
is  established,  systemic  medication  should  be  resorted  to  (within  the 
next  five  minutes,  if  possible).  Xo  time  should  be  lost,  as  every 
minute  is  valuable.  Either  salvarsan  or  mercury  should  be  given  at 
once.  The  plan  that  the  author  has  adopted  is  to  give  10  m.  of  1  per 
cent,  cyanide  of  mercury  solution  at  once,  and  as  soon  as  possible, 
preferably  within  the  next  two  hours,  a  full  dose  of  salvarsan  or 
neosalvarsan  intravenously. 

Status  of  Salvarsan  after  Five  Years. — Xotwithstanding  that  deaths 
have  occurred  both  in  this  country  and  abroad  following  the  use  of 


SYPHILIS  257 

salvarsan,  and  notwithstanding  differences  of  opinion  regarding  its 
value  and  toxicity,  the  author  believes  it  still  remains  the  most  power- 
ful spirillocide  that  we  possess.  If  used  with  discretion  and  judgment, 
it  is  the  most  valuable  single  weapon  we  have  in  combating  the  infec- 
tion, and  as  for  the  contra-indications,  in  small  doses,  not  to  exceed 
0.3  gm.  once  in  seven  to  ten  days,  the  author  believes  there  are  none. 
That  the  substance  is  neither  harmful  to  the  nervous  system  or  kidneys 
has  been  proved  by  Doinikow3  and  Wechselmann.15 

Unquestionably  the  fatalities  and  complications  laid  at  the  door  of 
salvarsan  are  errors  in  technic.  Briefly  and  in  order  of  their  frequency 
these  errors  are: 

1.  Use  of  water  that  contains  saprophytic  bacteria. 

2.  Oxidation  of  the  drug. 

3.  The  question  of  whether  the  solution  is  hypotonic  or  hypertonic. 
Considering  the  wide  use  of  salvarsan,  it  is  safe  to  say  that  95  out 

of  100  doses  are  given  with  water  that  is  neither  freshly  distilled, 
filtered,  or  sterilized,  and,  as  a  consequence,  toxic  effects  are  common. 
Few  users  of  salvarsan  or  neosalvarsan  realize  that  the  drugs  are  very 
unstable  and  that  oxidation  occurs  rapidly;  in  the  latter,  according  to 
Ehrlich,5  300  per  cent,  in  a  half-hour.  In  1916  supplies  of  salvarsan 
and  neosalvarsan  coming  from  the  manufacturers  in  Europe  seemed  to 
be  extremely  toxic.  How  this  is  accounted  for  the  author  cannot  say, 

Probably  few  observers  understand  that  distilled  water  is  capable  of 
dissolving  red  corpuscles,  and  writh  an  easy  water-soluble  salvarsan 
(as  neosalvarsan  is)  solutions  are  often  made  which  are  capable  of 
doing  this  in  the  blood  stream  after  they  are  injected.  This  is  particu- 
larly pointed  out  by  Ravaut.12 

For  the  sake  of  "safety  first,"  it  is  demanded  that  all  solutions 
be  made  with  freshly  distilled  (not  over  five  hours  old)  water,  properly 
filtered  and  sterilized.  The  solution  should  not  be  permitted  to  stand 
over  five  minutes  before  using  and  should  always  be  hypertonic. 

Number  of  Injections. — Primary  lesions  which  come  under  observa- 
tion before  the  Wassermann  is  positive:  Salvarsan,  0.6  gm.,  or  neo- 
salvarsan, 0.9  gm.,  should  be  given  once  every  week  for  four  weeks; 
then  one  month's  vigorous  rubbings  with  mercuric  ointment,  followed  by 
two  more  intravenous  injections  of  salvarsan  with  two  weeks'  interval. 
Primary  lesions  which  come  under  observation  after  the  Wassermann 
is  positive  should  have  salvarsan  or  neosalvarsan  every  week  for  four 
weeks,  to  be  followed  alternately  by  mercury  rubbings  and  salvarsan 
or  neosalvarsan  for  four  months,  giving  the  salvarsan  or  neosalvarsan 
every  month. 

Intravenous  Technic  for  Salvarsan. — The  instruments  are  one  large 
250  c.c.  cylinder  (Fig.  146,  B),  filter  papers,  one  funnel,  one  intravenous 
apparatus,  like  that  shown  in  Fig.  147,  one  graduated  pipette  (Fig. 
146,  A),  and  one  stock  bottle  of  normal  sodium  hydroxid  solution  (4 
per  cent.) 

The  instruments  and  filter  paper  having  been  previously  sterilized 
(which  may  be  accomplished  for  the  latter  by  moist  heat  and  later 
M  u  i — 17 


258 


GENITAL   ULCERS 


drying  between  sterile  towels,  and  for  the  ampoule  of  salvarsan  and  a 
file  by  immersion  in  alcohol),  the  ampoule  is  opened  with  the  sterile 
file  and  the  contents  poured  into  the  cylinder.  As  this  salt  goes  into 
solution  very  much  more  readily  than  the  earlier  supplies  of  the  sub- 
stance, it  is  not  necessary  to  add  any  glass  pearls  to  assist  in  the  mixing. 
Fifteen  cubic  centimeters  of  hot  water  are  added,  and  the  salt  put  into 
solution.  Next  the  normal  sodium  hydroxide  solution  is  added  (about 
2  c.c.),  and  shaken  thoroughly.  A  precipitate  occurs.  Then  sodium 


A  B 

FIG.    146. — Graduated  pipette  (A). 
Large  250  c.c.  cylinder  (B). 


FIG.  147. — Corbus's  intravenous 
apparatus. 


hydroxide  solution  is  added,  drop  by  drop,  the  solution  being  shaken 
after  each  drop  until  it  is  absolutely  clear,  care  being  taken  not  to  add 
an  excess.  Next  distilled  water  is  added  up  to  260  c.c.  The  whole 
is  then  filtered  into  the  receptacle  which  accompanies  the  intravenous 
apparatus.  Here  the  outlet  is  in  the  side  of  the  cylinder,  slightly 
above  the  bottom,  forming  a  little  receptacle  that  holds  any  foreign 
material  that  may  get  into  the  cylinder,  thus  ensuring  the  injection  of 
a  more  perfect  solution.  It  is  not  necessary  to  use  normal  saline 
solution,  as  the  above  solution  is  very  nearly  isotonic. 

The  arm  is  thoroughly  scrubbed  and  a  constrictor  placed  above  the 


SYPHILIS  259 

elbow.  After  taking  care  that  the  solution  runs  through  the  tube  and 
needle  easily,  and  that  it  is  not  above  98.6  F.,  and  that  air  bubbles  are 
absent,  the  needle  is  thrust  into  the  vein,  great  care  being  used  not  to 
puncture  the  vein  except  to  enter  its  lumen,  for  any  of  the  solution 
elsewhere  than  in  the  vein  will  produce  a  marked  paraphlebitis.  With 
the  two-way  cock  attachment,  it  is  easy  to  tell  when  one  is  in  the  lumen 
of  the  vessel,  as  the  blood  will  come  pouring  out.  Then  remove  the 
constriction,  turn  the  cock  and  send  the  solution  into  the  vein.  With 
the  cylinder  raised  28  to  30  inches  above  the  patient's  head,  and  with  an 
18-to  20-gauge  needle,  the  solution  will  enter  the  vein  in  from  seven 
to  twelve  minutes. 

It  is  true  that  filtering  the  solution  may  seem  to  be  superfluous,  but 
often  the  salt  agglutinates  and  there  are  small  gelatinous  particles  that 
do  not  dissolve;  and  again,  sometimes,  there  may  be  some  splintering 
of  glass  in  opening  the  ampoule.  Therefore,  in  order  to  carry  out 
this  technic  in  the  best  possible  manner,  it  is  better  to  filter  the  solution 
so  that  it  will  be  perfect. 

When  the  solution  has  passed  into  the  vein  and  the  injection  is  at 
an  end,  the  two-way  cock  is  turned  so  that  the  blood  returns  through 
the  side  outlet.  In  this  way  it  is  possible  to  wash  the  puncture  area 
with  the  patient's  own  blood,  thus  avoiding  the  Use  of  salt  solution. 

Neosalvarsan  may  be  given  with  the  same  apparatus  in  concentrated 
solution,  or  by  means  of  a  20  c.c.  syringe. 

The  author's  experience  with  many  hundreds  of  cases,  dating  since 
the  year  1910,  has  been  devoid  of  accidents  or  deaths  and  the  above 
technic  for  salvarsan  administration  has  been  used  exclusively. 

Intramuscular  Technic  for  Salvarsan. — All  intramuscular  injections 
of  either  salvarsan  or  neosalvarsan  should  only  be  mentioned  to  be 
condemned.  It  is  true  that  the  method  prolongs  the  elimination  of 
the  drug,  but  it  is  attended  by  severe  pain  and  induration,  often 
followed  by  abscess  and  necrosis. 

The  time  of  the  presence  of  the  primary  lesion  is  ideal  for  intra- 
venous medication,  as  it  catches  the  spirochetes  during  their  passage 
through  the  tissues. 

(6)  Ulcerated  Papule. — Occasionally  during  the  period  of  secondary 
invasion  numerous  ulcerated  papules  are  seen  on  the  genitalia. 
This  is  more  frequent  in  the  areas  in  which  there  is  less  moisture  in 
contradistinction  to  the  condylomata,  which  occur  on  moist  surfaces. 

The  diagnosis  should  not  be  difficult,  as  secondary  lesions  are,  as  a 
rule,  found  on  other  parts  of  the  body.  The  Spirochseta  pallida  are 
easily  demonstrated  by  means  of  the  dark-field  condenser  and  the 
Wassermann  is  always  positive. 

(c)  Gumma.  Chancre  Redux. — Quite  frequently  are  seen  the 
so-called  chancre  redux,  which  is  nothing  more  than  a  recurrence  at 
the  site  of  the  previous  primary  sore.  They  may  appear  any  time  from 
a  few  weeks  after  the  healing  of  the  primary  sore  to  ten  to  twelve 
years  afterward.  Occurring  after  several  years,  they  are  regarded  as 
gummata  by  most  observers. 


260  GENITAL   ULCERS 

Without  any  exact  time  of  exposure  or  apparent  period  of  incuba- 
tion, a  small  localized  papule  makes  its  appearance  and  rapidly  breaks 
down  and  ulcerates,  forming  a  typical  solitary  cutaneous  gumma. 
The  diagnosis  should  not  be  difficult  with  a  previous  history  of  lues. 

There  is  no  question  but  that  this  form  of  lesion  has  been  frequently 
reported  as  a  "second  case  of  lues  in  the  same  individual,"  but  this 
was  before  the  discovery  of  the  Spirochseta  pallida  and  the  Wassermann 
reaction.  It  is  possible  always  to  find  the  spirochetes  in  a  primary 
lesion  and  never  possible  to  find  them  in  a  chancre  redux  with  the  dark- 
field  condenser  or  any  staining  method.  As  the  spirochetes  are  found 
deep  in  the  tissues,  however,  their  demonstration  after  the  tissue 
method  of  Levaditi  is  possible.  Treatment  should  be  vigorous  and 
systematic. 

(rf)  Esthiomene  or  Syphilitic  Hypertrophy  of  the  Vulva  with  Ulcer- 
ations. — The  term  esthiomene,  established  in  medical  literature  by 
Huguier  in  1849,  has  been  misunderstood  and  misapplied  by  many 
authors. 

In  June,  1913,  Dr.  Lena  Kurz8  reviewed  the  literature  to  date  and 
demonstrated  clearly  that  this  clinical  entity  is  a  manifestation  of 
tertiary  syphilis.  She  says  in  part  as  follows: 

"A  careful  analysis  of  the  cases  of  esthiomene  that  we  were  able 
to  study,  and  the  vast  amount  of  literature  published  on  the  subject, 
led  us  to  the  conclusion  that  it  is  a  manifestation  of  tertiary  syphilis 
and  that  the  syphilitic  virus  is  the  sole  cause  of  the  condition.  There 
can  be  no  doubt  that  a  number  of  accessory  factors  have  a  marked 
influence  on  the  course  and  appearance  of  the  esthiomene,  but  they 
could  not  be  mistaken  for  the  causes  of  a  state  which,  considered 
from  every  possible  point  of  view,  bears  the  stamp  of  syphilis.  Such 
accessory  causes  are  inflammation,  abscesses,  uncleanliness,  and  above 
all,  a  low  state  of  health  aptly  termed  by  the  French  'la  misere  physio- 
logique.'  That  irritation  with  inflammation  of  the  parts  can  be  the 
sole  causative  agent  of  a  state  characterized  by  deep  and  wide-spreading 
ulceration  extending  into  the  pelvic  organs,  is  inconceivable.  Xor  can 
we  understand  how  recent  authors  can  read  'tuberculosis'  into  a  case 
of  esthiomene,  which  is  so  different  in  appearance,  histology,  symptoms 
and  results  from  a  tuberculous  state  of  the  vulva.  A  case  of  esthiomene 
is  occasionally  encountered,  which  may,  at  the  outset,  simulate  tuber- 
culosis, cancer  or  indurative  elephantiasic  edema.  Such  cases  are, 
however,  rare,  and  a  careful  inquiry  into  the  history  of  the  case  cannot 
fail  to  enlighten  the  student  regarding  the  class  of  disease  to  which  such 
a  case  should  be  relegated.  When  a  portion  of  tissue  can  be  removed 
for  examination,  a  first  glance  through  the  microscope  reveals  its  true 
nature.  A  positive  Wassermann  reaction  will  confirm  it.  With  our 
present-day  knowledge  of  the  bacillus  of  Koch,  the  Spirochaeta  pallida, 
the  tissues  of  gummata,  cancer,  etc.,  and  with  the  serum  test  for 
syphilis,  no  mistake  regarding  the  diagnosis  of  esthiomene  can  arise. 
In  recent  years  the  term  lupus  vulva  has  characteristically  given 
place  to  'tuberculosis  of  the  vulva,'  and  the  name  ulcus  vulva?  has 


SYPHILIS  261 

been  dropped.  Huguier's  term  'esthiomene'  is  now  but  rarely  used, 
which  seems  a  matter  for  regret,  for  if  used  in  the  definitely  under- 
stood sense  that  it  is  a  tertiary  syphilitic  manifestation,  it  replaces  the 
cumbersome  expression  'syphilitic  hypertrophy  of  the  vulva  with 
ulcerations.' ' 

The  disease  occurs  among  the  poor  and  neglected.  Servants, 
laundry  workers,  wives  of  soldiers  and  sailors,  are  among  the  most 
frequent  sufferers.  Sterility,  relative  and  absolute,  is  common.  The 
disease  is  most  common  between  the  ages  of  twenty  and  forty,  yet  it 
may  appear  before  or  long  after  that  age. 

A  granuloma  appearing  in  the  region  of  the  perineum  after  a  long 
period  of  apparently  perfect  health  is  a  common  manifestation  of 
"latent  syphilis." 

Symptoms. — Esthiomene  may  persist  for  many  years  without  pro- 
ducing any  marked  change  in  health;  however,  it  is  most  frequently 
accompanied  by  anemia,  lassitude,  headache,  and  rashes. 

It  is  surprising  how  little  inconvenience  esthiomene  may  cause  the 
sufferer.  Some  apply  for  medical  relief  early  because  they  are  alarmed 
by  the  presence  of  the  ulcers  and  the  thickening  of  the  parts;  others 
do  not  come  for  advice  until  itching  or  discharge  cause  inconvenience. 
At  present  it  is  uncommon  for  patients  to  wait  for  relief  until  the 
ulceration  has  attacked  the  urethra,  bladder  or  rectum.  There  is 
rarely  any  pain,  and  examination  of  the  parts  causes  no  suffering.  The 
painlessness  of  syphilitic  ulcers  is  a  characteristic  feature. 

Enlarged  Inguinal  Glands. — The  presence  or  absence  of  enlarged 
inguinal  glands  does  not  influence  the  diagnosis  of  esthiomene.  Where 
enlarged  glands  are  reported,  it  is  frequently  the  case  that  esthiomene 
has  supervened  on  the  secondary  stage  of  syphilis.  With  extensive 
ulceration  of  the  vulva  it  is  natural  to  find  "septically  infiltrated" 
glands.  Such  glands  are  usually  large,  firm,  elastic  and  isolated, 
easily  distinguished  from  the  hard,  small,  shotty  buboes  connected 
writh  each  other  by  thick,  stringy  lymph  channels,  so  typical  of  early 
syphilis.  Both  types  of  glandular  enlargements  may  be  present  in 
esthiomene.  Often  no  infiltration  is  palpable,  even  in  a  severe  case. 

Cicatricial  Tissue  in  Tertiary  Syphilis. — The  cicatricial  tissue  which 
follows  in  the  wake  of  syphilitic  ulceration  is  characterized  by  its 
bulk,  its  tendency  to  contract  strongly  and  to  break  down  again  into 
ulceration.  These  features  we  find  present  in  the  fibrous  tissue  follow- 
ing esthiomene.  The  deformity  found  may  be  enormous,  the  parts 
being  anatomically  unrecognizable;  strictures  follow  even  slight  degrees 
of  esthiomene;  repeated  breaking  down  of  healed  ulcerations  and  of 
hypertrophied  masses  are  characteristic  of  the  chronic  condition. 

Duration,  Course,  and  Causes  of  Death. — The  chronicity  of  esthiomene 
is  a  significant  feature.  All  syphilitic  ulcers  are  notoriously  slow  to 
progress  and  slow  to  heal.  In  no  other  ulcerative  condition  is  the 
history  so  prolonged,  so  eventful  of  recurrences,  and  so  little  disturbing 
in  its  effects.  The  course  depends  largely  on  the  early  recognition 
and  treatment  of  the  condition.  It  may  last  a  few  months  only,  result- 


262 


GENITAL    ULCERS 


ing  in  cure,   or  a   great   many  years,  with  death  of  the  patient. 
Phagedena  is  a  rare  complication. 

Pathology. — The  hypertrophied  masses  of  esthiomene  are  gummatous 
and  consequently  undergo  the  same  fate  as  gummata  elsewhere.  They 
necrose,  leaving  indolent,  chronic,  slow-spreading  ulceration.  The  cell 
elements  are  the  same  as  those  of  gummata;  the  inflammatory  cells 
are  mostly  plasma  cells  and  lymphocytes.  Numerous  capillaries  are 
present;  the  fibrous  coats  of  vessels  are  also  thickened,  even  at  an  early 
stage.  Later  the  intima  of  the  vessels  is  also  thickened.  At  any 
period  of  the  existence  of  the  gumma  it  may  break  down.  This 


FIG.  148. — Syphilitic  hypertrophy  of  the  vulva,  with  ulcerations  (low  power).  Shows 
very  dense  fibrous  tissue  of  old  standing  with  many  wavy  strands  of  connective-tissue 
fibers  and  few  cell  elements.  The  bloodvessels  are  exceedingly  sclerosed;  the  connective- 
tissue  laminae  in  the  vicinity  show  a  concentric  arrangement  around  the  vessels.  Exten- 
sive fatty  degeneration  of  the  tissues  is  taking  place.  (From  Lena  Kurz's  article.) 


breaking  down  may  occur  early  when  the  surrounding  tissues  of  the 
necrosed  area  are  still  infiltrated  with  plasma  cells  and  the  granulation 
tissue  is  new  and  vascular.  Or  it  may  occur  later  when  the  well- 
formed  connective  tissue  has  already  settled  down  into  strands  of 
wavy,  fibrillated  bundles.  At  an  early  stage  the  necrotic  cells  look 
uniformly  granular  and  gelatinous.  A  zone  of  small,  darkly  stained 
cells  surrounds  the  necrosing  area.  Beyond  it  we  find  the  ring  of 
never-failing .  fibrous  tissue,  from  which  cicatrizing  processes  will 
spread  inward  when  necrosis  is  completed  and  the  broken-down  tissues 
are  discharged  (Figs.  148  and  149). 
The  sections  of  tissues  from  the  appended  cases  show  all  these 


SYPHILIS 


263 


features.  There  are  numerous  areas  where  fat  deposits,  degenerating 
cells  and  spaces  of  uniform  appearance  without  cell  elements  mark  the 
areas  of  impending  necrosis.  We  find  them  surrounded  by  rings  of 
small  round  lymph  cells  and  plasma  cells.  At  the  edges  of  the  hyper- 
trophied  masses  we  note  the  presence  of  fibrosis  in  every  stage  of 
formation. 

Treatment. — 1.  Local. — Strict  cleanliness  is  of  extreme  importance. 
Frequent  warm  baths  are  indicated.  The  bathing  of  parts  with  soothing 
lotions  (opium  when  there  is  itching)  keeps  them  quiescent  and  prevents 
rubbing  and  scratching.  Lotio  nigra  may  be  used  freely  and  the  perineum 


FIG.  149.- — Syphilitic  hypertrophy  of  the  vulva,  with  ulcerations  (high  power). 
Shows  inflammatory  tissue  of  fairly  recent  date.  The  chief  elements  are  large  numbers 
of  small  round  cells  which  form  very  dense  masses  in  some  parts  and  numerous  blood- 
vessels. Some  of  these  are  widely  dilated  and  engorged  with  red  blood  cells.  Others 
have  thickened  walls  surrounded  by  young  connective  tissue.  (From  Lena  Kurz's 
article.) 


should  be  kept  as  dry  as  possible  and  dusted  with  borax  and  calomel 
powder.  Ulcers  should  be  touched  with  5  per  cent,  solution  of  silver 
nitrate.  When  there  are  fistula3,  with  incontinence  of  urine  and  feces, 
special  care  should  be  taken  to  keep  the  perineum  clean. 

2.  Constitutional. — If  possible,  the  patient  should  remain  in  bed 
until  all  ulceration  is  healed.  In  severe  cases  when  there  is 
destitution,  a  prolonged  stay  in  hospital  should  be  enforced.  The 
object  is  to  prevent  all  irritation  of  the  parts,  to  enforce  absolute 
cleanliness,  to  improve  the  general  condition  of  health  by  regular  and 
ample  feeding,  and  to  obtain  facilities  for  consecutive  medicinal  treat- 


264  GENITAL   ULCERS 

ment.  "With  such  means,  early  and  slight  cases  of  esthiomene  often 
yield  rapidly  and  remain  cured. 

The  main  medicinal  treatment  consists  in  the  administration  of 
mercurials  and  of  potassium  iodide.  The  mode  of  administration, 
dosage,  and  length  of  period  during  which  the  medication  is  employed 
will  depend  on  the  nature  and  stage  of  each  case.  The  salvarsan 
treatment  should  be  tried  whenever  it  is  possible  to  employ  it. 

3.  Operative. — Operative  measures  are  frequently  indicated  and  prove 
of  great  value  when  no  response  to  medicinal  treatment  has  been 
observed,  when  the  hypertrophy  is  increasing,  and  the  ulceration 
continues  to  spread.  Operative  treatment  consists  in  removing  the 
hypertrophied  masses  en  bloc.  Sometimes  a  considerable  portion  of  the 
vulva  has  to  be  sacrificed.  When  superficial  callous  ulceration  exists, 
scraping  of  the  floor  and  edges  is  beneficial.  When  the  ulceration  is 
deep  and  burrowing,  scraping  is  of  no  avail.  Fistulre  cannot  be  closed 
by  operations  on  account  of  the  unsoundness  of  the  neighboring  tissues. 
Strictures,  after  the  healing  of  surrounding  portions,  may  be  dilated, 
but  this  is  not  always  successful. 

Surgical  treatment  should  never  replace  medicinal.  Even  if  by 
operation  the  parts  are  apparently  cured,  antisyphilitic  treatment 
must  be  persevered  with  for  fear  of  recurrence. 

We  may  here  say  a  word  on  the  early  removal  of  a  portion  of  tissue 
for  microscopic  examination.  This  should  be  done  as  soon  as  the 
patient  comes  for  treatment.  Such  a  procedure  may  reveal  malignant 
disease  when  it  is  sometimes  least  suspected. 

2.  EROSIVE  AND  GANGRENOUS  BALANITIS. 

THE  FOURTH  VENEREAL  DISEASE. 

Definition. — Erosive  and  gangrenous  balanitis  is  a  specific  infectious 
disease  with  local  and  constitutional  symptoms  varying  with  the 
severity  of  the  infection. 

Etiology. — The  cause  is  a  symbiosis  of  a  vibrio  and  a  spirochete. 
These  two  organisms  are  always  found  together  in  the  affection.  Both 
have  been  demonstrated  in  sections,  in  the  bloodvessels,  and  in  the 
inguinal  nodes. 

Predisposing  Causes. — 1.  A  long,  tight  foreskin  excluding  the  air  to  a 
greater  or  less  degree. 

2.  Wetting  the  labia  or  penis  with  saliva. 

3.  Unnatural  sexual  relations  after  alcoholic  excesses. 

In  private  practice  in  this  country  the  disease  is  uncommon,  probably 
occurring  once  in  200  cases;  but  in  dispensary  work,  in  which  material 
comes  from  the  lower  walks  of  life,  the  infection  is  fairly  common. 
Scherber20  reports  81  cases  that  occurred  in  Finger's  clinic  in  four  years. 

Bacteriology. — Abundant  evidence  is  at  hand  to  show  that  in  noma 
and  in  Vincent's  angina  the  etiological  factors  are  a  spirochete  and  a 
vibrio.  Rona  says  that  "  noma  begins  without  exception  in  gangrenous 


EROSIVE  AND  GANGRENOUS  BALANITIS 


265 


stomatitis.  If  the  fusiform  bacillus  and  spirochete  found  in  the  mouth 
are  etiological  factors  in  gangrenous  stomatitis,  since  the  organism  is 
found  in  such  abundance  in  noma,  it  must  be  due  to  the  same  cause." 


FIG.  150. — Vibrio  and  spirochete;  culture  from  case  of  noma.     Slide  and  culture  by 

Dr.  Ruth  Tunnicliff. 

In  the  first  publication  of  the  writer  on  this  subject17  numerous 
authors  were  cited  and  abundant  clinical  proof  was  obtained  to  sub- 
stantiate the  pathogenicity  of  these  organisms. 


FIG.  151. — Etiological  factors  in  erosive  and  gangrenous  balanitis.     (Author's  case.) 

The  author  has  repeatedly  examined  the  spirochetes  found  in 
Vincent's  angina  under  the  dark-field  illuminator.  Here  the  organism 
is  identical  with  that  found  in  erosive  and  gangrenous  balanitis,  the 
motility  being  one  of  the  characteristic  and  diagnostic  features. 


266  GENITAL   ULCERS 

Since  the  conditions  that  favor  the  growth  01  these  organisms— 
heat,  moisture,  filth,  and  absence  of  air — are  more  ideal  in  the  genitalia 
than  in  the  mouth,  it  is  easy  to  conceive  how  an  organism  may  leave  its 
normal  saprophytic  domain  and  under  proper  anaerobic  conditions 
become  pathogenic  and  produce  extensive  destruction. 

Examinations  of  vaginal  secretions  of  100  normal  women  showed 
bacteria  and  spirochetes  similar  to  those  found  in  smegma,  but  no 
spirochetes  of  balanitis. 

In  11  cases  of  clinically  evident  vulvitis  and  vaginitis,  vibrios  and 
spirochetes  were  found. 

Etiology. — As  shown  in  Fig.  151,  the  vibrio  and  spirochete  are  the 
predominating  organisms  found.  We  can  easily  argue,  as  did  Rona, 
in  1905,18  that  if  the  fusiform  bacillus  and  the  spirochete  found  in  the 
mouth  are  etiological  factors  in  gangrenous  stomatitis  and  gingivitis, 
erosive  and  gangrenous  balanitis  must  be  due  to  the  same  cause,  since 
the  organisms  are  found  in  such  abundance  in  these  conditions,  and 
especially  since  in  the  histories  of  all  my  cases  unnatural  sexual  relations 
or  a  wetting  of  the  labia  were  admitted. 

The  vibrio  growls  under  anaerobic  conditions  on  serum-agar.  It 
occurs  single  or  in  chains  of  two  or  more  individuals.  It  is  a  slightly 
curved,  rod-shaped  organism  with  pointed  ends,  measuring  about  2 
microns  in  length  and  0.8  micron  in  width.  It  stains  by  the  ordinary 
dyes  and  is  Gram-positive,  although  the  decolorization  must  be  per- 
formed very  carefully,  as  the  organism  gives  up  the  gentian  violet 
readily.  It  is  preferable  to  use  70  per  cent,  alcohol  for  this  purpose. 

The  spirochete  is  Gram-negative,  but  stains  with  the  ordinary  dyes; 
with  the  Giemsa  stain  it  takes  a  bluish  red.  These  organisms  are  best 
seen  with  the  dark-ground  illuminator.  They  average  from  6  to  30 
microns  in  length  and  about  0.2  micron  in  width.  The  windings  are 
not  acute  and  the  ends  of  the  organism  terminate  in  the  centre  of  the 
spiral.  The  motion  of  the  organisms  is  very  rapid;  they  travel  from 
place  to  place,  resembling  small  snakes;  they  have  a  rotary  motion, 
but  this  is  not  so  pronounced  as  the  backward  and  forward  motion. 

After  unsuccessful  attempts  at  animal  inoculation  with  cultures, 
Scherber  does  not  believe  in  the  pathogenicity  of  the  fusiform  bacillus, 
and  considers  the  spirochete  responsible  for  the  lesions. 

A  rapid  and  simple  method  of  collecting  the  pus  is  by  capillary 
attraction  with  small  capillary  pipettes.  These  may  be  pushed  deep 
into  the  ulcers  and  a  quantity  of  fresh  discharge  obtained.  The  pus 
may  be  examined  with  the  dark-field  illuminator,  or  fixed  and  dried  and 
stained  from  two  to  three  minutes  with  carbol-fuchsin.  It  is  to  be 
examined  without  cover-glass  with  oil  immersion. 

Pathology. — The  pathological  condition  in  the  milder  forms  of  bal- 
anitis erosiva  circinata  consists  simply  of  a  flaking  off  of  the  epithelium, 
leaving  small  superficial  erosions.  When  the  desquamation  is  more 
marked  there  are  bright  red  ulcers,  which  are  surrounded  by  a  small 
white  zone,  the  remains  of  the  necrotic  epithelium  (Figs.  152  and  153). 

In  the  surrounding  tissue  there  is  an  exudation  of  leukocytes  and 


BROS/ \'K  A\'D  GANGRENOUS  BALANITIS 


267 


plasma  cells.  The  organisms  are  found  in  the  necrotic  membrane. 
At  times  they  can  be  demonstrated  in  the  tissues  and  bloodvessels,  as 
shown  by  Scherber  and  Miiller.19 


. 


•cr^ 


FIG.  152. — Erosive  and  gangrenous  balanitis  (low  power).  Shows  the  epithelium 
flaked  off  at  the  site  of  a  small  superficial  erosion.  There  is  an  exudation  of  leukocytes 
but  in  contradistinction  to  chancroid  and  chancre  this  is  not  marked.  The  vascular 
tissue  is  not  increased.  (Author's  case.) 


FIG.  153. — Erosive  and  gangrenous  balanitis  (high  power).  Shows  a  bloodvessel 
with  moderate  amount  of  leukocytes  in  adventitia.  There  is  no  proliferation  of  the  endo- 
thelial  lining  or  occlusion  of  lumen.  (Author's  case.) 


268  GENITAL   ULCERS 

In  the  more  severe  grades  of  infection  there  is  more  venous  stasis 
and  more  exudation,  resulting  in  marked  phimosis,  which  predisposes 
to  gangrene.  As  Scherber  and  Miiller  pointed  out,  the  whole  condition 
is  one  of  degree  only,  but  for  clinical  purposes  we  may  distinguish  two 
types  (1)  balanitis  erosiva  circinata,  and  (2)  balanitis  gangrenosa. 

Symptoms. — -Balanitis  erosiva  circinata  commences  with  the  appear- 
ance of  one  or  more  small,  grayish-white  patches  in  the  preputial  sac. 
At  the  time  of  the  development  of  the  erosion  an  offensive  thin  pus  is 
produced  of  a  characteristic  stinking  odor  and  of  the  usual  yellowish 
white ;  in  the  more  severe  cases  it  becomes  grayish  white  or  grayish  brown. 

Pus  from  the  lesions  is  innocuous.  In  its  development  the  inocula- 
tion never  becomes  pustular,  but  necrosis  of  the  epithelium  always 
represents  the  beginning,  and  the  future  process  is  polycyclic. 

Infection  shows  a  preference  for  the  sulcus  coronarius,  next  on  the 
inside  of  the  prepuce,  and  last  on  the  glans.  In  development  all  of  the 
glans  penis  is  involved,  and  under  favorable  anaerobic  conditions  the 
whole  fossa  navicularis  is  affected.  It  must  be  borne  in  mind  that  more 
or  less  phimosis  is  an  essential  factor. 

In  the  mild  cases  the  foreskin  may  be  easily  retracted,  but  in  the 
more  severe  forms  marked  phimosis  develops;  there  is  considerable 
itching  and  burning  behind  the  glans;  the  act  of  urination  is  practically 
without  pain.  In  contradistinction  to  the  gangrenous  form,  in  this 
type  of  the  disease  constitutional  symptoms  are  slight  or  absent. 

As  the  process  follows  no  hard-and-fast  lines,  there  are  certain  devia- 
tions from  the  foregoing  picture.  The  process  may  be  limited  to  the 
glans  and  the  inner  surface  of  the  foreskin  may  be  unaffected.  This 
may  be  extreme  or  mild,  but  it  is  always  present  on  the  covered  portion 
of  the  glans. 

The  inflammatory  condition  may  remain  a  purely  erosive,  superficial 
process  and  may  recover  spontaneously.  Berdal16  says  that  in  simple 
cases  healing  takes  place  in  four  or  five  days.  Scherber  has  seen  spon- 
taneous healing  almost  completed  in  forty-eight  hours  by  simple  wash- 
ing and  admission  of  air  by  retracting  the  foreskin.  He  further  states 
from  observation  that  the  height  of  the  development  usually  occurs  in 
from  four  to  eight  days  after  exposure  to  infection,  and  that  he  had 
seldom  seen  cases  of  four  weeks'  incubation  and  cases  persisting  for 
three  or  four  weeks. 

In  a  number  of  cases  the  process  does  not  remain  superficial,  but 
develops  deep  diphtheritic  and  gangrenous  ulcers,  which  complicate 
the  clinical  picture  in  many  ways. 

In  some  cases,  when  the  foreskin  can  be  retracted,  after  removal  of 
the  pus,  small,  round  ulcers  can  be  seen  inside  of  the  erosions,  varying 
in  size  from  that  of  a  pin-head  to  that  of  a  pea.  These  ulcers  are 
moderately  deep  and,  on  the  whole,  flat  and  surrounded  by  a  red  zone. 
They  are  covered  by  a  closely  adherent  pseudomembrane.  In  other 
cases  the  ulcers  are  more  extensive  and  deeper,  the  average  size  being 
about  that  of  a  dime.  These  may  become  confluent  and  extend  over 
the  whole  surface  of  the  sulcus  or  the  inner  surface  of  the  foreskin. 


EROSIVE  AND  GANGRENOUS  BALANITIS  269 

These  balanitic  ulcers  are  of  a  somewhat  irregular  outline,  and  are 
surrounded  by  small  inflammatory,  slightly  elevated  borders.  These 
borders  are  clean  cut  and  the  sides  somewhat  slanting;  the  bases  are 
uneven,  with  a  firm  yellowish-white  or  yellowish-brown  membrane, 
which  is  often  edematous  and  swollen.  When  more  edematous,  this 
false  membrane  appears  as  a  sort  of  friable  slime.  Here  and  there 
may  be  hemorrhagic  spots  which  sometimes  give  rise  to  hemorrhages 
from  the  base  of  the  ulcer. 

In  the  severe  forms  the  constitutional  symptoms  are  more  marked. 
Scherber  and  Miiller  noticed  chills  and  fever  in  a  majority  of  their 
cases,  and  at  the  onset,  vomiting.  The  average  temperature  ranges 
from  100°  to  101°  F.  There  is  marked  edema,  the  external  skin  being 
red  and  edematous;  the  infiltration  may  extend  to  the  root  of  the  penis 
in  some  cases.  The  dorsal  lymph  cord  is  usually  palpable  and  the 
inguinal  nodes  are  enlarged,  but  not  painful.  Unless  the  phimosis  is 
complete  there  is  no  pain  on  urination;  when,  however,  the  urine  is  not 
able  to  pass  freely  and  dilates  the  preputial  sac,  there  is  considerable 
pain. 

The  discharge  is  the  most  profuse  in  this  type  of  the  disease.  By 
gently  irrigating  the  preputial  sac  with  sterile  water  and  wiping  the 
external  urethra!  orifice,  gonorrhea  can  easily  be  excluded  by  using  the 
two-glass  urine  test. 

In  the  majority  of  cases  of  balanitis  gangrenosa,  there  occurs  a 
marked  edema  of  the  subcutaneous  tissue  of  the  penis  which  extends 
to  the  root  and  causes  a  marked  phimosis.  If  the  ulcer  is  situated  on 
the  inner  surface  of  the  foreskin,  it  shows  externally  as  a  dark,  bluish-red 
area  within  the  surrounding  bright  red  inflammatory  tissue.  The  con- 
gestion and  abnormal  pressure,  due  to  edema,  favor  the  progress  of  the 
disease. 

Soon  the  foreskin  over  the  ulcer  becomes  black,  and  a  complete 
necrosis  of  the  part  occurs.  If  the  ulcer  is  situated  on  the  glans,  in  a 
short  time  it  may  produce  complete  destruction  of  the  glans  or  may  even 
cause  an  extremely  rapid  gangrene  of  the  organ,  which  may  extend 
even  to  the  root  of  the  penis,  as  may  be  seen  by  the  author's  fourth 
case,  herein  described. 

The  ulcers  in  these  cases  are  deep,  the  edges  sharp  and  perpendicular, 
the  base  grayish  green  or  brownish ;  or  the  penis  may  show  hemorrhagic 
areas  or  be  changed  into  a  black  necrotic  mass. 

The  discharge  at  this  time  is  more  offensive  than  in  the  erosive  type; 
it  is  grayish  yellow  or  yellowish  brown,  and  at  times  it  may  be  slightly 
hemorrhagic,  but  always  with  the  same  characteristic  odor.  The 
inguinal  nodes  are  enlarged ;  there  is  a  mild  grade  of  sepsis  present,  and 
general  malaise  is  marked.  There  may  be  vomiting  and  the  tempera- 
ture may  reach  104°  F.  The  tenderness  of  the  part  is  extreme. 

Diagnosis. — This  disease  is  not  so  uncommon  as  one  might  suspect. 
Unfortunately  it  is  usually  mistaken  for  chancroidal  infection.  The 
period  of  incubation  may  be  the  same  in  the  two  conditions;  but  with 
the  characteristic  thin  yellowish-white,  offensive  discharge,  in  which  one 


270  GENITAL   ULCERS 

finds  a  vibrioform  organism  and  a  spiroehete,  the  diagnosis  should  not 
be  difficult. 

The  ulcers  of  the  two  forms  of  infection  may  simulate  each  other 
very  closely.  In  this  form  of  balanitis,  when  the  infection  is  at  all 
severe,  there  is  marked  phimosis  and  considerably  more  inflammatory 
reaction.  The  enlarged  inguinal  lymph  nodes  are  painless,  while  with 
a  very  insignificant  chancroidal  sore  a  suppurating  bubo  is  often  present. 

( 'hancroidal  ulcers  are,  as  a  rule,  multiple,  but  they  do  not  spread 
with  great  rapidity  as  do  those  of  the  ulcerative  form  of  balanitis. 
Whereas  the  borders  of  the  ulcers  in  both  diseases  have  a  clean-cut, 
punched-out  appearance,  there  is  greater  tendency  to  undermine  the 
wall  in  a  chancroidal  infection. 

On  account  of  the  indolent  adenopathy  that  accompanies  balanitis 
erosiva,  it  must  be  differentiated  from  syphilis.  In  syphilis  the  period 
of  incubation  is  longer,  although  the  two  infections  may  occur  simul- 
taneously, as  reported  in  one  of  Scherber's  cases,  as  well  as  in  one  of  my 
own.  When  such  a  condition  exists,  we  may  be  compelled  to  defer  our 
diagnosis  of  syphilis  until  the  period  of  incubation  for  syphilis  has 
elapsed;  or  in  case  of  a  mixed  lesion,  the  Spirochaeta  pallida  may  easily 
be  demonstrated  by  the  dark-ground  illuminator,  and  is  so  characteristic 
as  to  be  easily  differentiated  from  the  spirochete  of  balanitis. 

Herpes  preputialis  always  occurs  as  groups  of  small  insignificant 
vesicles  in  which  local  reaction  is  mild  or  entirely  absent.  This  con- 
dition simulates  the  mild  form  of  balanitis  erosiva  somewhat,  but  in 
herpes  one  fails  to  find  the  organisms  characteristic  of  balanitis. 

Treatment. — As  a  prophylactic  measure,  the  practice  of  circumcision 
should  be  encouraged ;  it  is  absolutely  impossible  for  balanitis  to  exist 
in  a  person  who  has  been  circumscribed. 

In  many  cases  in  which  the  condition  is  mild  and  the  foreskin  can 
easily  be  retracted,  all  that  is  necessary  is  a  thorough  cleansing;  but  in 
the  mild  ulcerative  forms  in  which  there  is  the  slightest  evidence  of 
phimosis,  a  dorsal  incision  should  be  made.  As  the  organism  of  bal- 
anitis is  anaerobic,  this  incision  serves  the  twofold  purpose  of  admitting 
air  and  of  exposing  the  diseased  parts  for  treatment. 

The  natural  tendency  in  this  disease  is  to  burn  all  the  sloughing 
ulcers,  but  such  treatment  subjects  the  patient  to  needless  punishment. 
As  said  before,  the  organisms  of  the  disease  are  anaerobic,  and  as  hydro- 
gen peroxide  liberates  oxygen  when  in  contact  with  organic  matter,  it 
acts  as  a  specific  for  this  form  of  infection. 

The  ordinary  2  per  cent,  solution  is  sufficient,  but  in  severe  cases  of 
gangrenous  balanitis  stronger  solutions  of  peroxide  may  be  procured 
and  painted  on  the  parts. 

REPORT  OF  CASES. 

CASE  I. — Erosive  type  (Fig.  154),  previously  reported. 
History. — The  patient,  M.  M.  W.,  aged  forty  years,  married,  denied 
all  previous  venereal  history.     After  four  days'  incubation  the  patient 


EROSIVE  AND  GANGRENOUS  B  ALAN  IT  IS 


271 


noticed  itching  and  burning  around  the  glans  penis.  There  were  no 
constitutional  symptoms.  During  the  first  week  this  continued  as  a 
mild  balanitis.  The  patient  was  able  to  retract  the  foreskin.  Treat- 
ment was  neglected.  At  the  end  of  the  first  week  conditions  suddenly 
became  worse;  the  foreskin  began  to  swell  and  the  patient  was  unable 
to  retract  it.  At  this  time  he  presented  himself  for  examination. 

Examination. — The  general  muscular  development  was  good;  there 
were  no  scars  or  evidence  of  previous  venereal  disease.  The  penis  was 
swollen  and  edematous;  the  edema  extended  about  half-way  up  the 
shaft  of  the  penis,  giving  it  a  pear  shape.  The  skin  over  the  glans 
portion  was  red  and  slightly  injected.  There  was  complete  phimosis. 
Exuding  from  the  opening  was  a  thin,  yellowish-white  pus,  with  a  pene- 
trating odor;  in  the  pus  a  vibrio  and  a  spirochete  were  found.  There 


FIG.   154. — Erosive  type,  Case  I.    Balanitis  erosiva    foreskin  not  retracted;  ulcers  seen 
on  margin.     (Author's  case.) 

was  constant  burning  pain,  which  was  increased  on  the  slightest  press- 
ure. There  was  no  urinary  pain.  The  dorsal  lymph  cord  was  easily 
palpable;  the  inguinal  nodes  were  enlarged  but  not  tender.  There  was 
no  fever. 

Treatment. — With  a  small  hard  syringe  2  per  cent,  hydrogen  peroxide 
was  injected  every  hour  into  the  preputial  sac.  By  the  second  day  the 
foreskin  could  be  retracted,  showing  numerous  small  ulcers  with  slough- 
ing bases  and  sharp  borders,  involving  the  sulcus  and  the  covered 
portion  of  the  glans. 

These  healed  rapidly  under  the  above  treatment. 

CASE  II. — Erosive  type,  complicated  by  syphilitic  infection. 

History. — C.  E.,  male,  aged  nineteen  years,  single.  No  previous 
venereal  disease;  gives  history  of  many  exposures.  Last  exposure  four 


272  GENITAL   ULCERS 

days  previous;  unnatural  relations.  After  six  days  of  incubation, 
patient  presented  himself  at  my  clinic  at  the  Post-Graduate  Hospital. 
Examination. — Well-developed  individual;  general  examination  neg- 
ative. Pulse  and  temperature  normal.  No  enlargement  of  the  lymph 
nodes;  profuse  yellow  discharge  from  the  preputial  opening.  Moder- 
ate amount  of  phimosis  present.  Foreskin  was  retracted  with  little 
difficulty,  showing  numerous  typical  superficial  erosive  ulcers,  both  in 
the  sulcus  coronarius  and  on  the  glans  penis.  Complicating  this,  how- 
ever, was  a  hard,  indurated,  erosive  chancre  seen  just  back  of  the 
corona  on  the  left  side.  The  sulcus  was  filled  with  purulent  discharge, 
as  seen  in  Fig.  155. 


FIG.  155. — Erosive  type,  complicated  by  syphilitic  infection,  Case  II.  Foreskin 
retracted;  grayish  purulent  secretion  in  sulcus  coronarius  and  a  few  small  erosions  on 
the  glans.  (Author's  case.) 

By  examination  with  the  dark-field  illuminator  it  was  possible 
to  make  a  differential  diagnosis  at  once,  for  there  were  present  the 
Spirochseta  pallida,  the  spirochete  of  erosive  and  gangrenous  balanitis, 
and  numerous  vibrios.  No  other  method  could  have  given  such  prompt 
diagnosis. 

Treatment. — Two  per  cent,  hydrogen  peroxide  and  salvarsan  with 
prompt  resolution  of  erosive  condition. 

CASE  III. — Erosive  type;  more  advanced  stage. 

History. — F.  P.  E.,  male,  aged  twenty-one  years,  single,  private 
patient.  No  history  of  any  previous  venereal  disease;  incubation  six 


EROSIVE  AND  GANGRENOUS  BALANITIS 


273 


weeks  (patient's  statement),  at  which  time  unnatural  relations  were 
had  with  the  idea  of  avoiding  exposure  by  the  ordinary  channels. 

ExaiuiuuHon. — Large,  corpulent  individual;  general  examination 
negative:  Pulse  and  temperature  normal.  Considerable  phimosis 
present;  penis  slightly  swollen.  Extreme  tenderness  on  examination. 
Foreskin  was  not  retractable;  patient  stated  that  during  the  month 
previous  there  was  a  little  itching  behind  the  glans,  but  that  twenty- 
four  hours  before  presenting  himself  for  examination  it  suddenly  began 
to  swell  and  was  extremely  painful  on  examination.  Profuse  stinking 
discharge.  Dorsal  lymph  cord  was  palpable;  slight,  painless  inguinal 
adenopathy  was  present. 


FIG.  156. — Erosive  type,  more  advanced  stage,  Case  III.  Foreskin  retracted  after 
dorsal  incision;  deep  erosive  ulcers  with  necrotic  bases  just  back  of  the  sulcus  coronarius. 
(Author's  case.) 


Operation. — Dorsal  and  ventral  incisions  were  made,  showing  both 
superficial  and  necrotic  ulcers  present  at  borders  of  glans  and  sulcus 
coronarius,  as  seen  in  Fig.  156.  Numerous  vibrios  and  spirochetes 
were  obtained  from  the  necrotic  ulcers. 

Treatment. — Two  per  cent,  hydrogen  peroxide,  thorough  cleaning 
with  hand  syringe  every  two  hours;  prompt  recovery;  unable  to  obtain 
second  photograph.  There  is  no  doubt  that  this  case  would  have  gone 
on  to  gangrene  had  not  prompt  treatment  been  instituted. 

CASE  IV. — Erosive  type. 

History. — P.  O.  S.,  male,  aged  twenty-six  years.  ,  History  of  previous 
gonorrhea.  Unnatural  relations  were  held  thirty-six  hours  previously. 

Examination. — Typical  pear-shaped  swelling  of  the  penis,  foreskin 
retracted.  Whole  of  glans  penis  and  sulcus  coronarius  covered  with 
superficial  ulcers;  average  size  about  the  head  of  a  pin;  profuse 

M  U      I — IS 


274  GENITAL   ULCERS 

purulent  discharge,  containing  vibrios  and  spirochetes.  Dorsal  lymph 
cord  palpable;  no  adenopathy. 

This  patient  was  so  slovenly  and  careless  that  after  two  days  of 
marked  improvement  he  discontinued  treatment  and  had  a  recurrence, 
with  a  later  cure. 

CASE  V. — Erosive  type;  previously  reported. 

History. — M.  "NY.  M.,  male,  aged  twenty-six  years.  Denied  syphilis; 
had  had  a  supposed  chancroidal  infection  two  years  previously.  Two 
weeks  before  presenting  himself  the  patient  had  intercourse.  After 
three  or  four  days  there  was  a  little  itching  beneath  the  prepuce.  At 
the  end  of  six  days  he  presented  himself  for  examination. 

Examination. — The  temperature  and  pulse  were  normal.  The  gen- 
eral nutrition  was  good,  and  there  were  no  signs  of  latent  syphilis. 
There  was  a  large  indurated  swelling  of  the  penis.  From  the  preputial 
orifice  exuded  a  thin,  yellowish-white,  stinking  discharge.  This  was 
examined  for  gonococci,  but  none  were  found.  There  was  phimosis, 
but  it  was  not  complete.  With  dilatation,  the  finger  was  gently  passed 
between  the  foreskin  and  the  glans.  The  whole  covered  portion  of  the 
glans  and  the  inner  leaf  of  the  foreskin  were  covered  with  small  ulcers, 
having  necrotic,  sloughing  bases.  Those  on  the  inner  leaf  extended  to 
the  border  of  the  preputial  fold ;  by  gently  pulling  back  the  foreskin  the 
whole  could  be  plainly  seen.  The  dorsal  lymph  cord  could  be  easily 
felt  and  the  inguinal  nodes  were  enlarged  but  not  tender.  There  were 
no  constitutional  symptoms. 

Treatment. — The  patient  was  given  a  wash  of  hydrogen  peroxide,  full 
strength  (2  per  cent).  As  he  did  not  return  to  the  clinic  it  is  pre- 
sumed that  his  condition  was  satisfactory 

CASE  VI. — Gangrenous  type,  previously  reported. 

History. — The  patient,  A.  G.  G.,  male,  aged  forty-three  years,  denied 
all  previous  venereal  history.  He  had  had  intercourse  nine  days  pre- 
viously; at  this  time  the  patient  said  that  the  prostitute  lubricated 
the  labia  with  saliva.  The  following  day  the  glans  portion  began  to 
swell;  there  were  chilly  sensations;  no  nausea  or  vomiting.  Previous 
to  this  time  the  patient's  glans  penis  was  exposed  between  the  preputial 
fold,  and  the  foreskin  could  be  retracted.  On  account  of  the  rapid 
phimosis  that  developed  this  could  not  be  accomplished  later.  The 
local  symptoms  increased  rapidly;  by  the  third  day  gangrene  had  set  in. 

Examination. — When  the  patient  presented  himself  at  the  clinic  he 
was  well  nourished;  muscular  development  good.  There  was  a  slight 
septic  intoxication.  The  entire  preputial  covering  for  a  distance  of 
three  inches  was  a  black,  necrotic  mass  (Fig.  157).  By  gentle  manipu- 
lation the  necrotic  mass  could  be  drawn  away  and  deep  sloughing  ulcers, 
with  sharp  borders,  could  be  seen  extending  into  the  penis  above  the 
glans.  There  was  considerable  thin,  slimy  pus  present,  with  an  odor  of 
necrotic  tissue.  Here  we  were  able  to  find  the  organism  in  large  num- 
bers. The  remaining  portion  of  the  penis  was  dark  red  and  infiltrated, 
the  edema  extending  to  the  root;  the  inguinal  lymph  nodes  were  en- 
larged. The  patient's  temperature  was  102°  F.;  malaise  was  marked. 


EROSIVE  AND  GANGRENOUS  BALANITIS  275 

Treatment. — The  patient  was  sent  to  the  County  Hospital.     Here 
the  necrotic  foreskin  was  cut  away,  and  just  above  the  glans  portion, 


FIG.  157. — Gangrenous  type,  Case  VI.    Appearance  on  examination.     (Author's  case.) 


FIG.  158. — Gangrenous  type,  Case  VI.    Appearance  forty-eight  hours  later. 
(Author's  case.) 


270 


(iKMTAL    ULCERS 


DIFFERENTIAL  DIAGNOSIS  BETWEEN   SYPHILITIC  CHANCRE,  CHANCROID,  HERPES,  AND 
EROSIVE  AND  GANGRENOUS  BALA.VITIS. 


Syphilitic  chancre. 

Chancroid. 

Herpes. 

Erosive  and  gan- 
grenous balanitis. 

Etiology 

Spirocha?ta    pal- 

Ducrey-Unna 

Xo  organism 

Symbiosis,  vibrio 

lida 

bacillus 

and  spirochete. 

Incubation 

Fourteen     to 

Two  to  five  days 

None 

Three     to     five 

twenty-one 

days;    may  be 

days 

longer. 

Location 

Generally     on 

Generally  on  gen- 

Generally    on 

Always  on  glans 

genitals;     may 

itals  ;  rarely  else- 

genitals ;     may 

penis      behind 

be  anywhere 

where 

be  anywhere 

closed  foreskin  ; 

may  extend  to 

adjacent  parts. 

Number 

Usually     single, 

Usually  multiple; 

Usually      multi- 

Usually multiple. 

but     may     be 

may  develop  ad- 

ple, later  con- 

double ;     must 

ditional  ulcers  at 

fluent 

be  so  from  on- 

any   time    dur- 

set 

ing   activity    of 

infection 

Auto-inoculable 

Possible    up    to 

Possible    at    any 

No 

Only  possible  un- 

ten days 

time 

der    anaerobic 

conditions. 

Onset 

Starts  as  erosion 

Pustule  or  ulcer 

Group    of    vesi- 

Small,    superfic- 

or papule 

cles 

ial  erosion. 

Course 

Remains  as  ero- 

Ulcer extends 

Forms      superfi- 

Becomes      con- 

sion   or    ulcer- 

cial ulcer 

fluent  ;      rapid 

ates. 

coalescence. 

Induration 

Usually    present 

Rare 

None 

Slight. 

Pain 

Little  or  none 

Very  painful 

Burning  and 

Very  painful. 

itching 

Shape 

Round    or    oval 

Round     or     oval 

Irregularly 

Irregular    round 

symmetrically, 

unsymmetri- 

rounded,     bor- 

or oval;  border 

irregular 

cally,  irregular 

der    polycyclic 

polycyclic. 

Depth 

Superficial,   cup- 

Deep,    excavated 

Superficial 

Superficial        at 

shaped  or  sau- 

or punched  out, 

first,    may   ex- 

cer-shaped ;  ma  y 

tend  deep. 

be  elevated 

Surface 

Smooth     and 

Rough,  moth- 

Bright  red  super- 

Rough   necrotic 

shining;    dark- 

eaten,    grayish, 

ficial    granula- 

centre; slightly 

ish    red    mem- 

warty     appear- 

tion 

reddened    bor- 

brane frequent 

ance 

der;    may    be 

yellowish- 

brown      mem- 

brane. 

Edges 

Sloping,  but  may 

Clean  cut,  may  be 

Sharp,    not    un- 

Clean   cut;    not 

be  elevated 

undermined 

dermined 

undermined  ; 

somewhat 

slanting   sides. 

Bottom 

Smooth  and  Uneven  and  irreg- 

Bottom       even  ; 

Gray  and  irregu- 

shining 

ular  ;    no    luster 

diffuse  inflam- 

lar;   no  luster. 

matory     tissue 

Secretion 

Slight  unless  ir- 

Abundant       and 

Slight,  seropuru- 

Profuse,      stink- 

ritated,      then 

purulent 

lent 

ing,     gray     to 

profuse;  serous 

grayish  -brown 

discharge. 

Adenitis 

Constant  ;   indo- 

When   present, 

No  glands 

Constant,    indo- 

lent 

always     inflam- 

lent. 

matory 

Gangrene 

Rare,  unless  com- 

Rare, unless  com- 

Never 

Often. 

plicated  by  ero- 

plicated by  ero- 

sive   and    gan- 

sive    and     gan- 

grenous balani- 

grenous    balani- 

tis 

tu 

EROSIVE  AND  GANGRENOUS  BALANITIS 


277 


at  the  site  of  the  inner  preputial  fold,  two  deep  ulcers  could  be  seen. 
The  glans  portion  was  necrotic.  In  forty-eight  hours  (Fig.  158)  the 
entire  glans,  together  with  about  one  and  a  half  inches  of  the  shaft  of 
the  penis,  sloughed  off,  leaving  a  short  stump  (Fig.  159).  The  patient 
was  treated  with  irrigations  of  potassium  permanganate  three  times  a 
day,  but  the  organism  had  already  invaded  the  deeper  layers,  and  gan- 
grene was  unavoidable. 


FIG.   159. — Gangrenous  type,  Case  VI.     Appearance  five  months  after,  showing  small 
stump  left.     (Author's  case.) 


B.  NON-VENEREAL   GENITAL   ULCERS. 

1.  Ulcers  accompanying  diabetes  found  on  the  glans  penis  of  the 
male  and  on  the  vulva  of  the  female,  usually  shallow  without  inflamed 
edges. 

2.  Ulcers  accompanying  infectious  diseases. 

(a)  In  measles,  usually  in  little  girls. 

(6)  In  diphtheria  caused  by  the  specific  bacillus.  Rare  in  the 
male,  but  sometimes  found  on  the  penis.  In  the  female 
found  chiefly  on  the  inner  side  of  the  labia  and  on  the 
clitoris.  In  appearance  like  venereal  ulcers,  but  dis- 
tinguished by  the  bacterial  findings. 

(c)  In  typhus  fever,  also  more  frequent  in  the  female. 


278  GEMTAL    ULCER* 

(d)  Tuberculous  ulcers;  rare  in  the  male,  more  frequent  in  the 
female;  usually  secondary  to  tuberculosis  in  neighboring 
organs,  but  may  be  due  to  direct  infection.  The  ulcers 
are  shallow,  with  their  edges  but  little  inflamed,  showing 
numerous  dentations.  The  base  of  the  ulcer  is  usually 
clear  and  granulating,  containing  small  grayish  nodules. 

3.  Ulcers  which  are  due  to  localization  of  skin  diseases  on  the  genitals. 

Herpes  Progenitalis. — These  ulcers  are  round  or  oval,  with  thin  edires 
often  showing  the  characteristic  grouping  of  herpes,  but  not  invariably. 
Found  in  the  male  on  the  prepuce,  glans,  or  sulcus ;  in  the  female  mostly 
on  the  labia. 

Etiology. — Predisposing  Causes.— It  is  said  to  be  more  common  in 
those  who  have  venereal  diseases.  Phimosis  with  retained  secretions 
and  coitus  are  exciting  factors.  Males  and  females  are  equally  affected. 
Bergh11  claims  that  it  is  more  frequent  in  women  at  the  time  of 
menstruation. 

Herpes  progenitalis,  the  same  as  herpes  in  other  parts,  is  due  to  a 
peripheral  neuritis,  and  may  depend  on  reflex  irritation  of  neighboring 
ganglia  due  to  local  or  internal  secretions. 

Symptoms. — Herpes  progenitalis  begins  as  a  single  lesion  or  in  groups, 
the  same  as  are  seen  on  the  face  or  lips.  Slight  burning  and  itching 
are  first  noticed,  and  the  slightly  red  area  soon  develops  minute 
vesicular  points,  which  rapidly  increase  in  size  to  that  of  a  pin-head  or 
slightly  larger.  Frequently  these  lesions  become  chafed,  causing  rup- 
ture of  the  vesicles,  the  area  becomes  confluent  or  presents  several 
small  excoriated  areas  which  become  irritated  by  secretions  and  slight 
infections  of  ordinary  pathogenic  organisms. 

Diagnosis. — In  an  individual  recently  exposed  sexually,  presenting 
a  confluent  patch  of  herpes  that  have  become  excoriated,  the  diagnosis 
should  not  be  attempted  without  a  careful  examination  for  spirochetes. 
In  the  early  cases,  however,  the  distinct  vesicles,  rapid  onset,  and 
absence  of  glandular  swelling  should  be  conclusive. 

Treatment. — Prophylactic. — Where  phimosis  is  present,  circumcision 
should  be  performed.  Frequent  washing  of  the  parts  should  be 
attended  to.  As  this  condition  is  self-limited,  in  the  doubtful  cases 
where  there  is  any  question  of  a  diagnosis,  all  treatment  should  be 
withheld.  Where  the  diagnosis  is  positive,  however,  simple  ointments 
or  dusting  powder  are  satisfactory. 

3.  CHANCROID. 

Synonyms. — Simple  ulcer;  simple  venereal  ulcer;  soft  chancre  or  ulcus 
molle. 

Definition. — A  specific  infectious  ulcer  usually  acquired  during  the 
sexual  act,  almost  always  situated  upon  the  genitals,  but  may  be 
found  on  any  part  of  the  body. 

Etiology.  —  A.  Prcduporing  Causes. —  (1)  Race  —  most  frequent 
among  colored  people.  (2)  Phimosis,  causing  retained  secretions. 


CHANCROID  279 

(3)  Filth  and  poverty  and  debauchery  and  degeneration  go  hand  in 
hand  with  this  infection;  as  a  consequence,  it  is  more  frequent  in 
dispensary  practice  than  in  private  work.  During  the  author's 
five  years'  experience  at  the  Post-Graduate  Hospital,  situated  in  the 
centre  of  Chicago's  "red-light"  district,  he  was  particularly  struck 
by  its  frequent  occurrence  in  the  colored  race.  (4)  Poor  and  ill- 
nourished  individuals  do  not  resist  the  infection  well. 

B.  Exciting  Cause. — Ducrey-Unna  bacillus. 

Description. — It  is  a  short  rod-shaped  bacillus  with  slightly  rounded 
extremities,  occurs  often  in  chains,  sometimes  in  groups,  either  in 
cells  or  between  them,  and  is  readily  stained  with  methylene  blue, 
carbol-fuchsin,  or  borax-methyl-violet.  It  is  decolorized  by  Gram's 
method. 

On  account  of  the  contamination  by  extraneous  organisms,  the 
demonstration  of  the  Ducrey-Unna  bacillus  is  difficult;  however,  if 
the  ulcer  is  sealed  with  flexible  collodion  for  twenty-four  hours  to  kill 
all  the  extraneous  organisms,  the  finding  of  the  bacillus  should  not 
be  difficult. 

Pathology. — Microscopically,  there  is  found  at  the  bottom  of  the 
epithelial  erosion  an  infiltration  of  leukocytes,  which  extends  laterally 
only  a  little  beyond  the  hyperemia.  The  exciting  cause  of  the  ulcer, 
the  delicate  and  difficult  to  stain  little  rods  (Ducrey-Unna  bacillus) 
line  the  tissue.  These  bacilli  make  their  way  out  from  the  hyperemic 
area  along  the  course  of  the  lymph  spaces  into  the  lymphatic  channels; 
as  these  lie  open  with  unobstructed  lumen,  the  rapid  march  of  the 
infection  to  the  neighboring  glands  is  the  rule  (Figs.  160  and  161). 

As  a  consequence  of  secondary  infection  with  other  bacteria  gaining 
entrance  through  the  local  ulcer,  an  extended  necrotic  disintegration 
can  reach  into  the  surrounding  tissue.  This  may  extend  both  laterally 
and  deeply  and  lead  to  wide  destruction  of  tissue.  Such  a  condition 
is  known  as  phagedena.  Occasionally  the  lymphatics  that  drain  a 
given  ulcer  appear  as  red  streaks  or  lines,  passing  backward  to  the 
regional  lymphatic  glands.  These  are  easily  palpable  and  may  be 
quite  painful. 

Symptoms. — Incubation  twenty-four  hours  to  three  days;  occasion- 
ally five  to  nine  days  are  given  by  the  patient;  at  this  time,  however, 
the  ulcer  is  well  advanced. 

After  sexual  indulgence,  with  varying  periods  of  incubation,  a  small 
congested  spot  makes  its  appearance;  this  rapidly  forms  a  small 
macule  which  later  develops  into  a  pustule,  surrounded  by  a  hyper- 
emic zone.  This  usually  increases  rapidly  in  size,  the  superficial  layer 
of  the  cutis  is  either  pulled  off  or  falls  off,  revealing  an  ulcer,  the  exact 
size  of  the  superficial  crust. 

These  ulcers  are  deep  and  have  a  characteristic  punched-out  appear- 
ance. The  edges  are  steep  and  are  frequently  undermined.  -The  floor 
has  a  dirty  gray,  moth-eaten  appearance,  and,  until  this  dirty  gray, 
sloughing  base  is  replaced  by  granulation  tissue,  healing  will  never 
occur.  The  discharge  is  purulent,  profuse  and  may  be  bloody  at  times. 


280 


CEMTAL   ULCKh'S 


Constitutional  symptoms  are  absent  and  remain  so  unless  there  is 
lymphangitis  or  inguinal  adenitis. 


FIG.  160. — Chancroid  (low  power).  Shows  infiltration  of  stroma  with  lymphoid 
cells  and  polymorphonuclear  leukocytes.  No  increased  vascularization.  No  infiltration 
of  bloodvessel  walls.  (Author's  case.) 


- 

'  " 


FIG.  161. — Chancroid  (high  power).    Shows  bloodvessels  with  polymorphonuclear 
leukocytes  in  lumen,  but  no  thickening  of  walls. 


CHANCROID  281 

Pain. — In  contradistinction  to  the  specific  lesion  of  syphilis, 
chancroids!  ulcers  are  extremely  painful  and  are  capable  of  auto- 
inoculation,  often  spreading  to  a  great  extent.  A  single  ulcer  is 
seldom  seen;  multiplicity  is  the  rule. 

Location. — The  ulcers  are,  generally,  confined  to  parts  where  the 
greatest  friction  during  coition  takes  place.  In  the  female,  the  labia 
or  vestibule  is  most  frequently  involved;  occasionally  the  external 
urethra!  orifice  is  the  site  of  infection.  In  the  male,  abrasion  or 
tears  take  place  most  frequently  in  the  sulcus  coronarius,  around  the 
freimlum,  at  the  edge  of  the  prepuce  and  the  external  urethral  orifice. 
These  places  are  the  sites  of  predilection.  When  the  ulcer  is  situated 
at  or  within  the  external  urethral  orifice,  urination  is  always  painful. 
Occasionally  a  gland  follicle  becomes  the  site  of  infection ;  here  the  ulcers 
may  burrow  deep  and  undermine  the  surrounding  tissue  and  the  gland 
opening  may  be  the  smallest  part  involved. 

Mixed  Sore. — It  is  indeed  common  to  find  both  chancroid  and 
chancre  in  the  same  individual,  either  in  the  same  ulcer,  or  in  different 
ulcers.  Often  an  inflammatory  hardness  is  present  in  chancroid  that 
simulates  the  induration  of  the  specific  chancre. 

Diagnosis. — There  is  no  single  condition  that  receives  such  careless 
attention  as  do  simple  ulcers  that  occur  on  the  genitals.  Few  observers 
realize  the  importance  of  an  exact  diagnosis,  especially*  if  the  infection 
is  syphilitic.  Unfortunately,  the  Ducrey-Unna  bacillus  is  difficult,  to 
find  and  is  little  known  in  this  country.  Fortunately,  however,  a 
diagnosis  can  be  reached  by  exclusion,  which  is  just  as  accurate  and 
more  rapid  than  finding  the  exciting  cause  of  chancroid  itself.  Every 
genital  ulcer  should  be  examined  carefully  for  the  Spirochaeta  pallida 
and  search  continued  diligently  until  the  presence  of  the  organism  is 
excluded  before  any  mutilation  or  treatment  is  practised  in  the  way 
of  cauterization,  dusting  powders,  etc.  There  is  no  longer  any  excuse 
for  haphazard  diagnosis  in  genital  ulcers.  It  is  true  that  clinical 
appearances,  multiplicity,  lack  of  induration,  etc.,  may  be  clear  and 
characteristic,  but  no  one  should  permit  an  ulcer  to  come  under  his 
care  without  a  thorough  microscopic  examination. 

In  most  American  text-books  frequent  reference  is  made  to  gan- 
grenous conditions  that  often  accompany  chancroid.  This  condition, 
described  in  detail  in  the  latter  part  of  this  chapter,  is  caused  by  a 
symbiosis  of  specific  organisms.  Here  careful  microscopic  examina- 
tion with  the  clinical  history  will  permit  of  an  exact  diagnosis.  For 
further  discussion  on  the  diagnosis  of  chancroid,  see  Chapter  on 
Syphilis. 

Herpes,  occurring  on  the  genitals,  is  often  mistaken  for  chancroid 
infection,  unless  seen  during  the  vesicular  stage;  these  erosions  are 
superficial,  have  little  discharge  and  are  not  painful.  Lymphangitis 
and  adenitis  are  lacking;  microscopic  examination  is  negative. 

While  the  Wassermann  reaction,  the  technic  of  which  can  be  found 
in  any  modern  text-book  on  clinical  diagnosis,  is  absolutely  valueless 
as  far  as  an  early  diagnosis  is  concerned,  occasionally  an  ulcerated 


282  GENITAL   ULCERS 

papule  or  chancre  redux  (see  description)  may  simulate  chancroid 
infection.  Here  the  application  of  the  test  should  be  a  valuable  aid  in 
diagnosis;  however,  the  fact  should  not  be  lost  sight  of  that  the  con- 
sumption of  large  quantities  of  alcohol  just  before  the  test  is  made  may 
cause  a  negative  reaction  and  the  test  prove  worthless. 

Treatment. — Prophylaxis. — The  wearing  of  a  condom  during  the 
sexual  act  is  the  most  reliable  preventative;  thorough  cleansing  with 
soap  and  bichloride  (1  to  5000)  may  be  employed;  however,  the  latter 
will  not  always  prevent  infection. 

It  should  be  borne  in  mind  that  no  treatment  of  any  kind  should  be 
instituted  until  an  accurate  diagnosis  is  made;  then  treatment  should 
be  prompt  and  efficient. 

As  the  exciting  organism  lies  deep  in  the  tissues,  cauterization  has 
been  the  favorite  method  of  attack  for  years,  and  it  is  rather  strange 
that  so  many  different  caustics  and  methods  of  application  should  be 
recommended.  Taylor,  as  cited  by  Watson  and  Cunningham,14 
recommends  the  application  of  liquefied  phenol,  followed  immediately 
by  the  application  of  nitric  acid.  Care  should  be  taken  to  use  con- 
siderable pressure  and  to  undermine  the  edges,  without  touching  any 
of  the  healthy  skin  with  the  caustic.  This  is  a  favorite  method  of 
the  author. 

By  applying  the  phenol  first,  considerable  local  anesthesia  is  pro- 
duced, so  that  the  subsequent  burning  with  nitric  acid  is  not  so 
painful.  Under  no  consideration  should  phenol  or  silver  nitrate  be 
used  alone,  as  only  the  superficial  portion  of  the  lesion  is  scarified, 
underneath  which  infection  is  sealed  up  and  a  resulting  adenitis  is 
rapidly  manifested. 

lodoform  as  a  dusting  powder  is  superior  to  all  others;  its  odor  may 
be  destroyed  by  cumerine,  gr.  ij  to  §  j,  or  by  placing  in  the  bottom  of  a 
stocking  or  tobacco  pouch  ground  coffee,  over  which  a  layer  of  cotton 
is  placed.  The  affected  part  is  then  dusted  with  iodoform  and  tied 
into  the  sack. 

A  favorite  and  efficient  ointment  that  may  be  applied  is  the  following : 

lodoform 2.5 

Balsam  of  Peru 5.0 

Petrolatum 50.0 

The  use  of  dusting  powders  is  pernicious  and  is  to  be  condemned,  as 
most  of  them  have  no  real  antiseptic  properties  and  only  tend  to  crust 
over  the  lesion  and  hasten  absorption,  with  resulting  adenitis. 

Morton  recommends  the  chloride  of  zinc  pulp ,  which  is  prepared  by 
adding  a  few  drops  of  water  to  chloride  of  zinc. 

A  favorite  method  in  some  hospitals  is  the  continued  application  of 
phenol,  neutralizing  each  application  well  with  alcohol. 

Chancroid,  situated  at  the  urethral  orifice,  should  not  be  cauterized, 
if  it  is  at  all  possible  to  cause  its  healing  without  so  doing. 

Complications. — 1.  Phimosis. — This  condition  is  a  common  and  often 
troublesome  complication  of  chancroid;  the  condition  per  se  is  not  so 


INGUINAL  ADENITIS  OR  INGUINAL  BUBO  283 

serious  as  the  delay  in  the  diagnosis  of  the  ulcer  that  is  causing  the 
condition.  Often  it  is  possible  to  retract  the  skin  enough  to  obtain 
material  for  diagnosis.  However,  when  this  cannot  be  accomplished, 
prompt  incision  and  exposure  of  the  ulcer  is  recommended.  It  is  true 
that  the  line  of  infection  may  become  infected  if  chancroid  is  present, 
but  the  patient,  on  the  other  hand,  may  be  saved  from  the  period  of 
secondary  syphilitic  invasion,  and  this  is  worth  while. 

It  is  possible  in  some  cases  to  cause  a  resolution  of  the  condition 
by  immersing  the  glans  in  hot  water  and  irrigating  with  hydrogen 
peroxide. 

Ten  per  cent,  iodoform  in  glycerin  is  recommended  as  an  efficient 
method.  However,  all  palliative  treatment  should  be  discouraged 
until  a  positive  diagnosis  has  been  made. 

2.  Paraphimosis. — Occasionally  this  condition  is  seen   associated 
with  genital  ulcers.     Contrary  to  the  condition  of  phimosis,  there  is 
no  obscuring  of  the  etiological  factor,  and  after  a  diagnosis  has  been 
made,  either  incision  of  the  constricting  band  or  manual  reduction  can 
be  resorted  to. 

3.  Phagedena. — Before  the  days  of  antiseptic  surgery,  phagedena  was 
a  very  formidable  complication  of  chancroid.    Its  etiology  was  little 
understood.    We  have  come  to  know  that  the  Ducrey-Unna  bacillus  is 
always  present,  associated,  as  a  rule,  with  the  streptococcus,  although 
almost  any  pyogenic  organism  may  be  found  at  times.    Numerous 
text-books  still  confuse  phagedena  with  gangrenous  conditions  that 
occur  around  the  glans  penis.    It  must  be  distinctly  understood  that 
this  form  of  gangrene  has  a  distinct  and  separate  bacteriology  (see 
Erosive  and  Gangrenous  Balanitis),  and  should  no  longer  be  mistaken 
for  phagedena. 

Treatment. — As  this  condition  is  almost  always  associated  with 
debility  and  malnutrition,  tonics  and  supportive  treatment  should  be 
instituted.  Locally,  the  ulcers  must  be  cauterized,  so  that  nothing 
but  healthy  tissue  remains.  At  times  it  may  be  necessary  to  use  the 
actual  cautery.  A  continuous  hot-water  bath,  either  by  means  of  the 
sitz-bath  or  immersion  of  the  organ  in  a  vessel  of  hot  water,  greatly 
facilitates  resolution  and  repair. 

Sequelae. — (1)  Lymphangitis;  (2)  lymphadenitis. 

Lymphangitis  always  accompanies  chancroid  infection  in  a  greater 
or  less  degree,  and  in  the  milder  form  needs  no  treatment.  However, 
in  debilitated  individuals,  sometimes  this  is  very  severe  and  distressing. 
Continued  hot  soaking  or  hot,  moist  applications  should  be  employed, 
and  if  softening  and  fluctuation  become  manifest,  incision  should  be 
promptly  made. 


INGUINAL   ADENITIS  OR  INGUINAL  BUBO. 

This  is  a  frequent  and  severe  complication  following  chancroidal 
infection. 


284  GEMTAL    ULCERS 

Etiology. — 1.  Predisposing  Cause. — The  condition  occurs  frequently 
among  the  poor,  laboring  classes,  who  attend  the  free  dispensaries, 
for  among  them  heavy  lifting  and  walking  predispose  to  the  infection. 
Among  the  better  class  of  patients,  inguinal  adenitis  is  rather  infrequent. 

2.  Exciting  Cause. — The  exciting  cause  is  the  Ducrey-Unna  bacillus. 
The  chancroidal  form  of  infection  invariably  causes  an  inguinal  adenitis 
unless  the  primary  infection  is  attended  to  promptly. 

Symptoms.- — The  adenitis  generally  occurs  in  the  second  or  third 
week  of  the  chancroids,  unless  the  ulcers  have  been  carelessly 
cauterized,  in  which  case  it  occurs  earlier.  If  the  ulcer  is  on  the  right 
side,  the  right  inguinal  glands  become  involved;  if  on  the  left  side,  the 
left  side  is  involved ;  however,  when  the  ulcer  is  on  the  f renulum,  or  on 
both  sides,  either  or  both  sides  may  be  involved. 

Pain  is  the  first  symptom  that  attracts  the  patient's  attention,  and 
this  is  increased  writh  walking  or  the  slightest  exertion. 

On  palpation  the  individual  inguinal  glands  that  run  parallel  to  Pou- 
part's  ligament  are  easily  identified.  The  glands  are  hard  and  very 
tender  while  the  skin  over  the  mass  is  slightly  congested  and  freely 
movable.  At  this  period  the  glands  may  either  undergo  resolution  and 
recede  or  the  condition  may  become  progressively  worse.  Consider- 
able peri-adenitis  occurs,  the  glands  become  matted  together  in 
irregular,  tender  masses  and  adherent  to  the  skin  and  the  subjacent 
tissue;  the  former  becomes  boggy,  dusky  red,  and  edematous,  and  soft- 
ening occurs  rapidly,  in  some  cases  with  spontaneous  rupture.  Fre- 
quently the  exact  counterpart  of  the  chancroid  is  depicted  in  an  inguinal 
adenitis.  The  base  of  the  suppurating  glands  is -dirty  gray,  and  there 
is  extropion  of  the  walls  with  undermined  edges  (virulent  bubo). 

On  cross-section,  such  a  gland  shows  numerous  miliary  abscesses. 
Some,  of  course,  undergo  resolution,  but  many  break  down,  become 
confluent,  and  leave  the  whole  gland  as  an  abscess  cavity,  with  the 
gland  capsule  alone  as  the  limiting  membrane.  Occasionally,  the 
extension  of  a  phagedena  into  the  inguinal  adenitis  is  seen,  forming  a 
serpiginous  ulceration. 

Treatment. — Prophylactic. — The  prompt  and  early  surgical  treat- 
ment of  all  chancroidal  ulcers  (see  Treatment  under  Chancroid) 
should  be  resorted  to.  Never  cauterize  the  chancroids  with  silver 
nitrate  or  phenol  alone,  as  these  both  tend  to  seal  over  the  top  of 
the  ulcer  and  cause  absorption  from  the  under  strata,  which  invari- 
ably produces  an  adenitis  in  twenty-four  hours. 

Palliative.— The  sore- having  been  previously  cleansed  and  cauter- 
ized, the  parts  are  shaved  and  scrubbed,  hot  bichloride  (1  to  5000) 
or  boric  acid  dressing  are  applied,  the  patient  is  bandaged  firmly  with 
a  spica  bandage  and  put  to  bed. 

This  hot  dressing  is  changed  every  two  or  three  hours.  This 
procedure,  with  rest  in  bed,  will  cause  both  resolution  in  the  glands 
that  are  not  too  far  involved  and  will  hasten  softening  in  those  that 
are  far  advanced.  Continuous  wet  alcohol  dressings,  in  the  same  men- 
ner  that  the  wet  bichloride  dressings  are  applied,  may  help  to  cause 
resolution  in  some  cases.  Hyperemia  applied  after  the  method  of 


INGUINAL  ADENITIS  OR  INGUINAL  BUBO  285 

Bier  by  means  of  a  bell  glass  is  admirable  to  promote  resolution  and 
hasten  softening.  The  common  practice  of  painting  the  parts  with 
tincture  of  iodine  has  little  or  no  value. 

Surgical. — This  treatment  should  be  withheld  until  the  bubo  has 
softened  and  there  is  fluctuation;  then  simple  incision  at  right  angles  to 
Poupart%s  ligament  offers  the  best  method  of  drainage.  The  wound 
is  wiped  dry  and  packed  with  iodoform  gauze.  Frequent  swabbing 
with  tincture  of  iodine  and  dressing  with  wet  or  dry  gauze  offer  the 
best  means  of  causing  resolution. 

Except  for  the  management  of  chancroid  itself,  no  other  condition 
has  received  so  many  diverse  forms  of  treatment.  Complete  extir- 
pation of  the  glands  is  a  favorite  method  of  radical  cure,  but  unfortu- 
nately being  septic  in  the  beginning,  these  wounds  do  not  heal  kindly, 
and  occasionally  grave  complications  arise  from  wounding  of  deep- 
seated  bloodvessels  and  lymphatics. 

Frequently  the  chancroidal  adenitis  may  be  complicated  with  the 
indolent  adenitis  of  lues,  and  here  the  application  of  prompt  and 
energetic  specific  treatment,  as  a  rule,  causes  rapid  resolution. 

Phagedena  as  a  complication  of  adenitis  calls  for  heroic  treatment. 
The  patient  is  best  anesthetized,  and  with  the  actual  cautery  all 
infectious  and  necrotic  tissue  is  removed;  subsequently  the  ulcers  are 
treated  with  hot  dressings  and  tincture  of  iodine  irrigations. 

BIBLIOGRAPHY   ON   GENITAL   ULCERS. 

1.  Bergh,  R.:  Monatsh.  f.  prakt.  Dermat.,  1890,  x,  1. 

2.  Craig,  C.  F.,  and  Nichols,  Henry:  War  Dept.  Bull.  No.  3,  June,  1913,  p.  51. 

3.  Doinikow,  Boris:  Mlinchen.  med.  Wchnschr.,  1913,  Ix,  796. 

4.  Dreyfus,  Georges  L. :  Miinchen.  med.  Wchnschr.,  1912,  lix,  2567. 

5.  Ehrlich,  P.:  Ztschr.  f.  Chemotherap.  u.  verwandt.  Geb.,  1912,  i,  1. 

6.  Ellis,  Arthur  W.  M.,  and  Swift,  H.  M.:  Jour.  Exp.  Med.,  1913,  xviii,  162. 

7.  Jadassohn,  J.:  Arch.  f.  Dermat.  u.  Syph.,  1907,  Ixxxvi,  45. 

8.  Kurz,  Lena:  Jour.  Obstet.  and  Gynec.  Brit.  Emp.,  1913,  xxiii,  353. 

9.  Morton,  Henry  H. :  Genito-Urinary  Diseases  and  Syphilis,   Philadelphia,  F.  A. 
Davis  &  Co.,  1912. 

10.  Mott,  F.  W.:  The  Cerebrospinal  Fluid,  Lancet,  1910,  ii,  79. 

11.  Noguchi,  Hideyo:  Jour.  Am.  Med.  Assn.,  1913,  Ixi,  85. 

12.  Ravaut,  Paul:  Ann.  de  med.,  1914,  i,  49. 

13.  Schereschewsky,  J.:  Deutsch.  med,  Wchnschr.,  1913,  xxxix,  1310. 

14.  Watson,  F.  S.,  and  Cunningham,  John  H.:  Diseases  and  Surgery  of  the  Genito- 
Urinary  System.     Philadelphia,  Lea  &  Febiger,  1908. 

15.  Wechselmann,  Wilhelm:  Salvarsan  Therapy,  2d  ed. 

BIBLIOGRAPHY  ON  EROSIVE  AND  GANGRENOUS  BALANITIS;    THE 
FOURTH  VENEREAL  DISEASE. 

16.  Bataille  and  Berdal:  Med.  mod.,  1891,  ii,  340. 

Dind:  Rev.  med.  de  la  suisse  romande,  1911,  xxxi,  592. 

Ellerman:  Centralbl.   f.    Bakteriol.,    1905,   xxxviii,   383. 

Kallionzis,  E.:  'lav/oA/c/)  Trpoodof,  'Ev  2iy><j,  1910,  xv,  385. 

McDonagh:  West  Lond.  Med.  Jour.,  1911,  xvi,  131.. 

Romeo,  P.:  Gazz.  d.  osp.,  1910,  xxxi,  1257. 

Tunnicliff,  Ruth:  Jour.  Infect.  Dis.,  1906,  iii,  148. 

Tunnioliff,  Ruth:  Jour.  Infect.  Dis.,  1911,  viii,  316. 

Weaver,  G.  H.,  and  Tunnicliff,  Ruth:  Jour.  Infect,  Dis.,  1905,  ii,  446. 

17.  Corbus,  B.  C.,  and  Harris,  Frederick  G.:  Jour.  Am.  Med.  Assn.,  1909,  Iii,  1474. 

18.  R6na,  S.:  Arch.  f.  Dermat,  u.  Syph.,  1905,  Ixxiv,  171. 

19.  Scherber  and  M  tiller:  Arch.  f.  Dermat.  u.  Syph.,  1905,  Ixxvii,  77. 

20.  Scherber:  Handbuch  der  Geschlechts-Krankheiten,  1910,  i,  153. 


CHAPTER  IX. 

INFECTIONS  OF  THE  URETHRA  AND  PROSTATE  OTHER 
THAN  TUBERCULOSIS. 

BY  B.  S.  BARRINGER,  M.D. 

GONORRHEA. 

Prevalence  of  Gonorrhea. — It  is  highly  probable  that  every  male 
who  indulges  in  promiscuous  intercourse  sooner  or  later  acquires  a 
gonorrhea.  The  percentage  of  males  so  affected  varies  according  to 
different  authorities,  and  according  to  various  countries  between  50 
and  100  per  cent. 

"Morrow  estimates  that  60  per  cent.,  and  Forscheimer  that  51  per 
cent,  of  the  adult  male  population  of  the  United  States  have  gonorrhea. 
He  adds  that  20  per  cent,  of  these  young  men  will  become  infected 
before  they  are  twenty-one  years  of  age;  over  60  per  cent,  before  they 
pass  their  thirty-eighth  year."  (Keyes.)  These  are  statistics  of  nine 
years  ago.  Another  specialist  says,  "roughly  speaking,  one  may  say 
that  most  German  men  have  had  gonorrhea;  and  one  in  five,  syphilis." 

"Blanchko  calculates  that  among  clerks  and  merchants  in  Berlin 
between  eighteen  and  twenty-eight  years  of  age,  45  per  cent,  have  had 
syphilis  and  120  per  cent,  have  had  gonorrhea;  in  Breslau  77  per  cent, 
have  had  syphilis,  200  per  cent,  have  had  gonorrhea.  (If  the  percent- 
age of  gonorrhea  is  placed  at  200  per  cent,  the  average  is  two  attacks.)" 
(Flexner.)* 

"Among  women  gonorrhea  is  more  severe  and  less  common  than 
among  men.  The  proportion  of  men  to  women  is  16  to  1.  It  is  shock- 
ing to  learn  that  almost  one-third  ot  the  reported  cases  of  gonorrhea 
occurred  in  married  women  to  whom  the  infection  had  been  conveyed 
by  their  husbands." 

"In  the  United  States  Army,  in  prevalence,  gonorrhea  stands  first 
(12  per  cent.+) ;  as  a  cause  for  discharge  from  the  army  it  stands  fourth; 
as  a  cause  of  death  it  is  negligible."  (Keyes.) 

Reasons  for  Prevalence.— Illicit  intercourse  is  responsible  for  most 
gonorrheas.  To  study  the  reasons  for  the  prevalence  of  gonorrhea  is  to 
study  the  reasons  for  prostitution. 

Flexner  says:  "No  wonder  that  where  practice  is  so  general,  theory 
has  accommodated  itself  so  far  as  to  assume  that  sexual  intercourse  on 
the  male's  part  is  necessary  and  wholesome.  Up  to  recent  times  this 
has  been  an  undisputed  dogma.  The  universality  of  demand  has  been 
condoned  on  the  assumption  that  it  represented  an  irresistible  impulse. 

*  Flexner's  book  ' '  Prostitution  in  Europe  "  has  been  much  quoted  because  it  is  remark- 
able and  modern. 

(286) 


ANATOMY  OF   THE  MALE   URETHRA  287 

"  In  the  first  place,  however  strong  the  spontaneous  sex  impulse  may 
be,  it  is  really  like  any  other  impulse  capable  of  restraint  through  the 
cultivation  of  inhibition.  Except  for  the  futile  efforts  of  the  church, 
European*  society  has  for  centuries  been  singularly  free  from  any  such 
effort.  Women  have  been  regarded  as  inferior  creatures  and  have 
accepted  the  status  assigned  them;  they  have  therefore  failed  to 
resent  masculine  immorality.  The  restraint  that  might  thereby  be 
imposed  upon  men — be  it  much  or  little — has  been  generally  lacking. 
Europe  has  been  a  man's  world;  managed  by  men  and  largely  for  men; 
for  cynical  men  at  that.  Men  inured  to  the  sight  of  human  inequality; 
callous  as  to  the  value  of  lower  class  life,  and  distinctly  lacking  in  respect 
for  womanhood." 

The  unrestrained  masculine  sexual  impulse  accounts  for  a  certain 
amount  of  illicit  intercourse;  to  this  is  added  an  artificial  sexual  excita- 
tion, "an  artificial  supply  of  prostitutes  is  created  and  an  artificial 
demand  is  worked  up." 

A  striking  example  of  deliberate  business  organization  along  these 
lines  is  to  be  found  in  Paris,  where  close  adjoining  one  another  in  the 
Rue  Pagal  are  found  a  dance  hall,  a  cafe,  and  an  assignation  house 
under  one  management." 

The  Remedy. — The  remedy  does  not  lie  in  any  regulation  of  prosti- 
tution; in  any  segregation  of  prostitutes;  in  any  prophylactic  treat- 
ment; in  any  antigonorrheic  vaccination;  or  in  any  conscience-solving 
eugenic  test.  Flexner  says,  "  the  women's  movement  will  unquestion- 
ably destroy  the  passivity  of  German  women  in  respect  to  masculine 
irregularities."  This  would  seem  to  be  the  key  to  the  remedy.  In- 
sistence upon  the  part  of  wives  and  mothers  for  masculine  continence. 
The  old  and  absurd  physiological  objections  that  masculine  continence 
leads  to  various  nervous  disorders,  even  to  impotence,  still  are  wide- 
spread. Sexual  education  is  in  its  infancy:  "As  the  boy  matures,  the 
actual  danger  involved  in  immorality  may  be  so  depicted  as  to  exert  a 
detrimental  effect;  but  the  main  remedies  must  continue  to  be  from 
the  higher  motification."  In  some  sex  teaching  there  exist  curious 
practices;  for  instance,  the  young  man  is  urged  to  be  continent,  and 
at  the  same  time  told  how  to  use  preventatives. 

ANATOMY  OF  THE  MALE  URETHRA. 

The  urethra,  "the  outlet  of  the  bladder,"  extends  from  the  bladder 
neck  to  the  end  of  the  penis,  and  is  divided  into  a  posterior  (4  cm.)  and 
an  anterior  (12  cm.).  The  posterior  urethra  is  in  turn  divided  into  two 
parts:  a  prostatic  (2.5  cm.),  which  runs  from  the  bladder  sphincter,  or 
base  of  the  prostate,  through  the  prostate  to  its  apex;  and  a  membran- 
ous (1.5  cm.)  part  which  runs  from  the  apex  of  the  prostate  to  the  bulb. 
This  pierces,  is  limited  by,  and  receives  fibers  from  the  anterior  and 
posterior  layers  of  the  deep  perineal  fascia.  The  anterior,  spongy  or 

*  What  Flexner  says  of  Europe  is  true,  perhaps  in  a  lesser  degree,  of  the  whole  civilized 
world. 


288 


INFECTIONS  OF   URETHRA  AXD  PROSTATE 


penile  urethra  runs  from  the  triangular  ligament  to  the  end  of  the  penis, 
and  is  surrounded  by  the  erectile  tissue  of  the  corpus  spongiosum. 

Landmarks  of  the  Urethra. — The  only  part  of  the  urethra  visible 
is  the  meatus.  By  means  of  the  urethroscope  the  interior  of  the  urethra 
may  be  examined  throughout  its  length. 

The  Penile  Urethra. — The  penile  urethra  runs  from  the  meatus 
urinarius  along  the  under  surface  of  the  penis  (where  it  may  be  easily 
felt)  to  the  penoscrotal  angle,  thence  to  the  scrotoperineal  angle, 
where  it  may  be  palpated  by  depressing  the  scrotum.  The  anterior 
urethra  ends  in  the  bulb  whose  lower  limit  is  at  a  point  midway 
between  the  scrotoperineal  angle  and  the  centre  of  the  anus.  This 
spot  is  the  "central  tendon"  where  the  perineal  muscles  meet. 


FIG.  162. — The  lumen  of  the  urethra,  seen  in  a  sagittal  section:  1,  bladder;  2,  cul- 
de-sac  of  the  bulb;  3,  neck  of  the  bladder;  4,  prostatic  widening;  5,  narrowing  at  the 
membranous  portion;  6,  neck  of  the  bulb;  7,  penile  narrowing;  8,  fossa  navicularis;  9, 
meatus.  (After  L.  Testut.) 


Membranous  Urethra. — The  finger  introduced  into  the  rectum  will  feel 
the  membranous  urethra  on  the  front  wall  just  behind  the  internal 
sphincter  of  the  rectum.  It  runs  from  this  point  to  the  apex  of  the 
prostate,  which  can  be  felt  farther  up  the  rectum.  If  a  sound  is  intro- 
duced into  the  urethra,  the  membranous,  as  well  as  the  prostatic,  por- 
tions can  be  better  palpated.  This  method  of  palpation  is  especially 
valuable  to  determine  the  presence  of  an  early  carcinoma  of  the  prostate 
which  generally  starts  posteriorly  in  the  lobes  and  is  felt  between  the 
sound  and  the  rectum. 

Prostatic  Urethra. — This  runs  in  the  median  line  from  the  apex  of  the 
prostate  to  its  base  (felt  on  the  front  wall  of  the  rectum).  The  two 
lateral  lobes  of  the  prostate  may  be  felt;  but  it  takes  a  long  finger  to 


ANATOMY  OF  THE  MALE   URETHRA  289 

reach  much  above  the  base  of  the  prostate.  The  seminal  vesicles  are 
at  either  angle  of  the  base  of  the  prostate  and  extend  upward  and 
outward  along  the  bladder. 

Size  of  the  Urethra. — The  urethra  begins  at  the  vesical  orifice,  which  is 
wide,  usually  large  enough  to  admit  the  tip  of  the  index  finger,  and  may 
be  dilated  to  36  to  40  F.  It  becomes  still  wider  in  the  prostate,  but 
after  the  membranous  urethra  is  reached,  narrows  down  to  26  to  30  F. 
Again,  in  the  bulb  it  enlarges;  then  narrows  again  in  the  penile  portion, 
widens  out  in  the  fossa  navicularis,  and  narrows  down  again  at  the 
meatus.  The  meatus  is  the  narrowest  and  least  dilatable  part  of  the 
entire  urethra;  it  averages  24  F.  in  size. 

Interior  of  the  Urethra. — The  interior  of  the  urethra  is  not  a  smooth, 
unbroken  surface,  but  shows  small  and  large  indentations,  and  the 
orifices  of  glands. 

The  indentations  of  the  urethra  are  known  as  the  Lacunae  of  Mor- 
gagni,  and  are  situated  in  the  anterior  urethra,  the  large  ones  along  the 
roof  and  the  smaller  ones  along  the  sides.  They  are  like  pockets  in  the 
mucous  membrane  opening  toward  the  end  of  the  penis,  and  are  from 
5  to  12  mm.  deep.  On  the  roof  of  the  fossa  navicularis  is  an  unusually 
large  indentation,  the  lacuna  magna. 

The  ducts  of  various  glands  enter  the  urethra  directly  or  into  one  of 
these  lacunae.  The  lacunae  of  Morgagni  can  be  seen  through  the 
urethroscope,  but  the  openings  of  the  glands,  if  uninflamed,  are  gener- 
ally not  discernible. 

Glands  of  the  Urethra.— (1)  The  glands  of  Littre.  (2)  Cowper's 
glands.  (3)  The  prostate.  (4)  The  seminal  vesicles. 

The  glands  of  Littre  are  situated  chiefly  along  the  roof  and  sides,  a 
few  in  the  floor,  of  the  anterior  urethra ;  and  rarely  in  the  membranous 
and  prostatic  urethra.  They  lie  in  the  submucosa,  are  lined  with 
prismatic  epithelium,  have  a  duct  which  pierces  the  mucous  membrane 
obliquely,  and  opens  toward  the  end  of  the  penis.  They  normally 
secrete  mucus,  and  on  occasion  stubbornly  harbor  bacteria.  When 
normal,  they  cannot  be  palpated,  but  when  inflamed,  they  can  often 
be  felt  along  the  anterior  urethra  as  nodules  from  the  size  of  a  bird- 
shot  up. 

Cotcper's  glands  are  two  racemose  glands  as  large  as  a  bean,  situated 
on  either  side  of  the  membranous  urethra  just  behind  the  bulb  and  be- 
tween the  layers  of  the  triangular  ligament.  Their  ducts  are  30  to  40 
mm.  in  length,  run  along  the  urethra,  pierce  the  anterior  layer  of  the 
triangular  ligament,  and  enter  the  bulbous  urethra;  when  Cowper's 
glands  are  inflamed,  they  can  be  felt  with  one  finger  in  the  rectum  and 
one  on  the  perineum  on  either  side  of  the  membranous  urethra. 

The  prostate  gland  "belongs  physiologically  to  the  sexual  organs," 
and  is  somewhat  of  the  size  and  shape  of  a  horse-chestnut.  It  lies  with 
its  base  toward  the  bladder,  its  apex  against  the  posterior  layer  of  the 
triangular  ligament.  The  urethra  and  ejaculatory  ducts  run  through 
its  substance.  Its  glands  empty  by  ducts  (30  or  40)  into  the  prostatic 
urethra;  these  ducts  point  toward  the  apex  of  the  prostate. 

M  U       I 19 


290  IXFECTIOXS  OF    URETHRA   A.\D  PROSTATE 

Lowsley3  has  done  much  work  on  the  anatomy  of  the  prostate,  and 
I  quote  extensively  from  his  authoritative  work. 

"Wilson  and  McGrath  found  the  average  adult  gland  to  vary  in 
length  from  3.3  cm.  to  4.5  cm.,  with  an  average  of  3.4  cm.  In  width 
there  is  a  variation  from  3.4  to  4.5  cm.,  average  4.4  cm.  Thickness 
varies  from  1.3  cm.  to  2.4  cm.,  average  1.5  cm.  The  weight  averages 
16  or  17  grams. 

"The  prostate  gland  is  in  every  instance  divided  into  five  portions 
corresponding  to  the  five  original  groups  of  tubular  evaginations  noted 
in  the  embryo.  The  division  between  the  middle  and  two  lateral  lobes 
becomes  less  and  less  noticeable  as  age  advances,  but  the  orifices  of  the 
middle  lobe  tubules  are  in  every  instance  widely  separated  from  all 
other  tubular  orifices  and  quite  closely  grouped  together.  The  middle 
lobe  tubules  always  grow  backward  behind  the  vesical  orifice  outside 
of  the  broad  ribbon-like  sphincter  of  its  orifice  and  its  tubules  are 
never  found  imbedding  themselves  in  it  or  extending  within  the 
sphincter. 

"  The  lateral  lobes  during  the  period  of  middle  age  become  more  and 
more  prominent  and  cause  a  bulging  of  the  lateral  surfaces  to  a  marked 
degree,  thus  making  the  transverse  diameter  of  the  organ  proportion- 
ally greater  than  in  prepuberty  specimens. 

"The  posterior  lobe  is  fairly  well  separated  from  all  of  the  other 
portions  of  the  gland  and  is  divided  off  by  a  rather  firm,  and  in  some 
instances  quite  thick,  connective-tissue  partition.  It  is  always  present, 
as  is  the  lobe  itself,  and  is  intimately  attached  to  the  ejaculatory  ducts, 
which  are  not  imbedded  in  this  partition  but  seem  to  be  set  upon  its 
anterior  surface. 

"The  posterior  lobe  is  always  present  and  is  the  part  of  the  gland 
felt  per  rectum.  Its  tubules  are  in  most  respects  similar  to  those  of 
the  other  lobes. 

"The  anterior  lobe  varies  greatly  in  different  specimens.  At  the 
time  of  birth  it  consists  of  two  small  unimportant  tubules  with  very 
few  branches.  In  the  postpuberty  specimens  the  anterior  lobe  is 
quite  prominent  and  is  made  up  of  tubules  which  branch  extensively 
and  are  apparently  actively  secreting  prostatic  fluid. 

"The  branches  of  tubules*  all  extend  backward  toward  the  base  of 
the  prostate,  with  the  exception  of  a  few  of  the  most  anterior  tubules 
of  the  lateral  and  posterior  lobes.  The  collecting  ducts  are  situated 
at  the  most  anterior  portion  of  a  given  group  of  branches  and  pass 
quite  directly  toward  the  verumontanum. 

"In  the  verumontanum  the  tubules  turn  and  run  forward  for  a 
slight  distance  and  about  nine-tenths  of  them  open  on  the  lateral  walls 
of  the  verumontanum,  in  such  a  manner  that  there  is  a  little  leaflet 
of  tissue  covering  the  orifice,  which  is  an  exceedingly  important  factor 

*  Poroz9  has  studied  the  course  of  these  ducts  and  concludes  that  they  are  best  emptied 
by  massaging  the  gland  from  its  base  downward  toward  its  apex.  Gonococci  invade 
these  ducts  of  the  prostate,  in  every  posterior  urethritis,  and  it  is  here  that  they  most 
Btubbornly  persist. 


ANATOMY  OF  THE  MALE  URETHRA  291 

in  protecting  the  tubules  of  the  gland  from  an  inpouring  of  urine  and 
other  foreign  matter  when  the  posterior  urethra  is  put  under  pressure. 
The  direction  of  the  openings  of  the  tubules  of  the  prostate  and  ejacu- 
latory  ducts  is  an  important  consideration  also,  because  instrumenta- 
tion will  frequently  cause  an  infection  by  forcing  foreign  substances 
into  them.  In  the  adult  prostate  there  is  noted  a  great  change  in  the 
mucosa.  I  have  found  in  my  specimens  that  the  tubules  and  their 
branches  are  lined  by  a  single  layer  of  high  cylindrical  cells  with  the 
nuclei  at  their  bases.  In  some  places  there  is  a  piling  up  of  the  cylin- 
drical cells.  Near  the  orifices  of  the  ducts  the  epithelium  is  transi- 
tional in  type,  being  similar  to  that  of  the  urethra  itself. 

"The  capsule  of  the  prostate  is  composed  of  a  structure  which  is 
made  up  of  closely  knit  connective-tissue  fibers  and  surrounds  the 
entire  organ,  except  at  the  base  between  the  entrance  of  the  ejacula- 
tory  ducts  into  the  substance  of  the  prostate  and  the  junction  of  the 
bladder  wall  with  the  gland.  Here  the  tubules  of  the  middle  lobe 
are  almost  free  and  have  as  a  consequence  very  thick  muscular  and 
connective-tissue  walls.  The  large  bloodvessels  which  supply  the 
prostate,  run  in  the  capsule  and  intralobular  partitions  for  the  most 
part  and  are  most  numerous  on  the  anterior  portion  of  the  capsule. 

"  The  epithelium  of  the  vasa  deferentia  is  made  up  in  part  of  simple 
ciliated  columnar,  and  in  part  of  stratified,  ciliated,  columnarc  ells  with 
two  rows  of  nuclei.  The  cilia  are  often  absent,  however,  and  vary  a 
great  deal.  In  the  ampulla  of  the  vas  deferens  the  epithelium  is  for 
the  most  part  simple  columnar  in  type." 

The  seminal  vesicles  are  two  lobulated  pouches  between  the  base  of 
the  bladder  and  the  rectum.  They  are  about  7  cm.  in  length,  and  can 
be  felt  by  a  finger  in  the  rectum  extending  upward  and  outward  beyond 
the  margins  of  the  prostate.  When  normal,  they  can  be  felt  with 
difficulty,  and  when  enlarged,  only  the  lower  part  is  palpable. 

The  anterior  extremities  of  the  seminal  vesicles  converge  toward  the 
base  of  the  prostate  where  each  joins  the  corresponding  vas  deferens  to 
form  the  ejaculatory  ducts. 

The  canal  system  of  these  organs  is  intricate,  and  varies  in  different 
specimens  from  a  simple  straight  tube  to  tubes  with  many  twists. 
Either  the  straight  or  twisted  tubes  may  have  diverticula. 

The  blood  supply  is  from  the  middle  hemorrhoidal  and  the  inferior 
vesical  arteries  which  enter  the  vesicles  at  their  upper  and  outer  poles. 
"In  this  locality  the  vesicle  is  in  closest  relation  to  the  ureter." 

The  vesicles  have  a  thick  muscular  wall,  and  are  lined  with  cylin- 
drical epithelium  in  the  young  which  in  later  life  becomes  cuboidal. 

The  vesicles  in  addition  to  being  seminal  reservoirs  have  a  secretory 
function  and  add  one  of  the  important  constituents  to  the  semen. 

A  complete  understanding  of  the  pathology  and  treatment  of 
urethritis  rests  upon  a  knowledge  of  various  points  of  dissimilarity 
between  the  anterior  and  posterior  urethra.  The  following  is  a  table 
of  such  points: 


292 


INFECTIONS  OF   URETHRA   AND  PROSTATE 


ANTERIOR  URETHRA. 

Surrounded  by  erectile  tissue  (corpus 
spongiosum)  for  entire  length,  excepting 
for  \  inch  in  the  roof  cf  the  bulb. 

Many  glands  of  Littre  in  roof  and  sides. 

Ducts  of  Cowper's  glands  enter  bulb. 


"  External  urinary  tract  in  free  com- 
munication with  the  surface  of  the  body 
and  harbors  all  the  microorganisms  that 
may  be  thereon." 

Fixed  at  only  one  end  (triangular  liga- 
ment) therefore  can  assume  any  curve  {e.g., 
on  passing  a  sound)  without  causing  pain 
to  the  patient. 


Fluid  may  be  introduced  into  anterior 
urethra  and  held  there  by  compressing 
urethral  meatus. 


The  introduction  of  a  foreign  body  (e.  g., 
fluid  or  catheter)  into  the  anterior  urethra 
causes  only  pain  or  burning. 

Inflammation  causes  simply  pain. 

There  are  no  voluntary  muscles  sur- 
rounding the  anterior  urethra  which  can 
resist  the  introduction  of  a  fluid  or  an 
instrument. 


POSTERIOR  URETHRA. 
No  erectile  tissue  covering. 


Very  few  glands  of  Littre. 

Ducts  of  prostatic  glands  enter  pros- 
tatic  urethra. 

Verumontanum  with  ducts  c  f  seminal 
glands  in  prostatic  urethra. 

' '  The  lowest  section  of  the  aseptic 
internal  urinary  tract — entirely  free 
from  bacteria  harbored  by  anterior 
urethra.'' 

Fixed  at  one  end  by  the  triangular 
ligament  and  at  the  other  by  the  pros- 
tate; so  having  a  fixed  "U"  curve  which 
when  straightened  (for  example  on  intro- 
duction of  a  cystoscope)  causes  pain  to 
the  patient. 

Fluid  cannot  be  retained  in  posterior 
urethra..  The  compression  of  the  sur- 
rounding muscles  drives  it  either  back 
into  the  bladder  or  forward  into  the 
anterior  urethra. 

The  introduction  of  a  foreign  body 
(fluid  or  a  catheter)  into  the  posterior 
urethra  causes  pain  plus  a  desire  to 
urinate. 

Inflammation  causes  pain  plus  fre- 
quency of  urination. 

By  means  of  the  perineal  muscles  the 
introduction  of  an  instrument  or  fluids 
can  be  voluntarily  resisted;  therefore  go 
gently  as  the  sound  or  catheter  ap- 
proaches the  posterior  urethra. 


THE  GONOCOCCUS. 

Microscopic  Characteristics. —  Source  of  Specimen. — In  a  urethral 
gonorrhea  a  specimen  for  staining  is  most  often  obtained  by  pressing 
or  "milking"  the  urethra,  when  a  drop  of  pus  is  expressed.  If  there 
is  no  urethral  drop,  \ve  may  have  to  centrif ugalize  the  urine  which  has 
just  been  passed  and  examine  the  sediment;  or  we  may  have  to  fish  a 
shred  from  the  urine  with  a  pipette  or  platinum  loop.  The  shreds 
most  profitable  to  examine  are  those  small  ones  which  because  of  their 
richness  in  pus  and  paucity  in  mucus  fall  to  the  bottom  of  the  glass  of 
urine. 

If  the  prostate  and  seminal  vesicles  are  suspected  of  harboring  the 
gonococcus,  a  drop  of  pus  may  be  expressed  from  the  urethra  by  mas- 
sage of  these.  Sometimes  after  such  massage  the  prostatic  pus  does 
not  enter  the  anterior  urethra,  but  instead  is  forced  back  into  the 
bladder,  whence  it  may  be  obtained  for  examination  either  from  the 
patient's  passed  or  catheterized  urine. 

Preparation  of  Slide. — If  the  glass  slide  is  grease-free,  heat  is  the  only 
necessary  method  to  fix  the  specimen.  To  remove  the  grease,  wash  the 
slide  in  soap  and  water  before  using,  and  then  dry  it. 

Spreading. — The  drop  of  pus  to  be  examined  may  be  spread  upon 
the  slide  by  dipping  the  edge  of  another  slide  in  the  pus  and  streaking 


THE  GONOCOCCUS 


293 


it  along  the  first  slide.  Another  good  method  is  to  wind  the  end  of  a 
tooth-pick  tightly  with  cotton,  dip  this  into  the  pus  and  gently  streak 
the  pus  along  the  slide. 

Urinary  shreds  are  generally  too  thick  to  be  examined;  so  they  should 
either  be  flattened  by  pressing  between  two  glass  slides,  or  teased  out 
with  the  end  of  a  pipette. 

Fixing.— Allow  the  preparation  to  dry  in  the  air  and  then  pass  it 
several  times  through  a  Bunsen  flame. 

Staining.— Methylene  Blue. — The  smear  is  covered  with  a  saturated 
aqueous  solution  of  methylene  blue  for  five  seconds,  then  washed  in 
running  water,  dried,  and  examined  with  the  oil-immersion  lens. 


FIG.  163. — Photomicrograph  of  gonococci.      (Ed.) 

Appearance  of  Gonococci. — Typical. — The  gonococcus  of  Neisser  is 
morphologically  a  micrococcus  which  occurs  in  pairs  (diplococci), 
separated  by  a  fissure,  each  individual  being  kidney  or  coffee-bean 
shaped.  This  pairing  (occasionally  quadrupling)  is  in  marked  con- 
trast to  the  irregular  grape-like  massing  of  staphylococci,  and  the 
wreath  or  chain-like  arrangement  of  streptococci. 

Gonococci  have  an  affinity  for  the  protoplasm  of  pus  cells,  and  often 
completely  fill  the  cell. 

Atypical. — Gonococci  may  appear  wholly  between  the  pus  cells 
arranged  so  as  to  resemble  staphylococci  or  streptococci;  or  only  one 
or  two  may  appear  in  a  pus  cell. 

Value  and  Limitations  of  Methylene-blue  Stain. — Acute  Gonorrhea. — 
For  a  common  working  diagnosis  of  acute  gonorrhea  the  methylene- 
blue  stain  is  the  popular  stain,  and  with  it  to  supplement  the  clinical 


294  IXFECT/OXS  OF    URETHHA   A.\D  PROSTATE 

evidence  one  cannot  go  far  wrong.  If  the  gonococci  are  typical  as  to 
arrangement  and  intracellularity,  the  only  slip-up  that  can  occur  is 
through  mistaking  the  gonococcus  for  that  rare  inhabitant  of  the 
urethra,  the  Micrococcus  catarrhalis.  And  this  mistake  is  not  deadly, 
as  the  treatment  for  catarrhalis  urethritis  is  much  the  same  as  that 
of  gonorrhea!  urethritis.  //  the  cocci  examined  do  not  have  a  typical 
appearance,  then  a  Cram  stain  should  be  made. 

Chronic  Gonorrhea. — It  is  a  different  story  in  chronic  gonorrhea. 
Both  streptococci  and  staphylococci  may  be  mistaken  for  gonococci. 
The  Gram  stain  alone  is  of  value. 

The  methylene-blne  stain  should  never  be  used  to  verify  a  cure  of  gonor- 
rhea. 

Gram  Stain. — The  gonococcus,  in  addition  to  its  other  peculiarities, 
is  what  is  called  "Gram-negative,"  which  means  that  in  a  slide  which  is 
treated  by  Gram  stain  and  decolorized  by  alcohol  the  gonococci  do  not 
take,  or  are  negative  to  the  Gram  stain;  while  other  organisms  to  be 
differentiated  from  the  gonococci  are  supposed  to  take  or  be  positive 
to  the  Gram  stain. 

Staining  Slide. — The  smear  on  the  slide  is  prepared  as  outlined  above. 

"The  Gram  stain  is  so  frequently  carried  out  in  a  loose  and  inaccurate 
manner  that  it  seems  worth  while  to  note  the  method  of  staining 
employed  at  the  Cornell  laboratories.  It  is  essential  for  the  success 
of  this  stain  that  the  various  steps  be  measured  by  the  watch.  The 
film,  after  fixation  by  heat,  is  treated  with  an  anilin  water,  gentian- 
violet  solution  for  a  period  of  three  minutes,  blotted,  and  a  Lugol  solu- 
tion applied  for  two  minutes.  The  film  is  again  blotted  and  washed 
in  absolute  alcohol  for  thirty  seconds.  In  the  case  of  spreads  made 
from  exudates,  differentiation  in  absolute  alcohol  is  continued  for  a 
longer  period,  the  time  allowed  depending  upon  the  thickness  of 
the  film.  As  a  counter-stain,  a  very  weak  watery  solution  of  basic 
fuchsin  is  employed,  which  is  allowed  to  act  for  thirty  seconds.  The 
anilin  water,  gentian-violet  solution  is  made  up  according  to  the  fol- 
lowing formula:  Anilin  water,  3  parts;  absolute  alcohol,  7  parts; 
distilled  water,  90  parts.  This  mixture  is  thoroughly  shaken  and 
filtered  through  a  well-moistened  filter.  To  the  close  filtrate  add 
2  grams  of  Grubler's  powdered  gentian  violet,  shake  well,  and  set 
aside  for  twenty-four  hours.  For  staining  purposes,  pipette  off  the 
supernatant  fluid,  which  obviates  the  necessity  of  filtration.  This 
solution  will  keep  for  from  four  to  six  weeks,  and  does  not  immediately 
deteriorate,  as  is  popularly  supposed.  A  watery  solution  of  Bismarck 
brown  gives  a  better  counter-stain  than  the  basic  fuchsin,  unless  this  is 
employed  in  very  weak  solution  to  avoid  overstrain.  Unfortunately, 
the  brown  has  to  be  made  up  fresh.  (Keyes.) 

As  with  the  methylene-blue  stain,  the  Cram  stain  is  not  used  to 
verify  a  cure  of  gonorrhea. 

Method  Employed  for  the  Isolation  of  the  Gonococcus. — To 
establish  the  diagnosis  of  gonorrhea  beyond  all  question  of  doubt  the 
isolation  and  identification  of  the  specific  causative  agent  is  essential. 


THE  GONOCOCCUS  295 

Absolute  certainty  concerning  this  point  is  demanded  only  i-n  certain 
cases  of  medicolegal  importance  (rape,  divorce,  etc.). 

In  acute  cases  the  recovery  of  the  gonococcus  from  the  discharge, 
as  a  rule,  presents  no  difficulties,  providing  suitable  culture  media  are 
selected  for  this  purpose.  In  chronic  cases  success  depends  upon  the 
selection  of  the  most  favorable  culture  medium  for  the  development  of 
the  gonococcus  and  upon  adherence  to  certain  details  in  securing  the 
material  for  examination  and  preparing  the  cultivation.  But  even 
under  the  most  favorable  circumstances  repeated  examinations  are 
frequently  required  before  a  definite  opinion  concerning  the  nature  of 
the  disease  can  be  given. 

The  method  given  below  has  been  followed  in  the  bacteriological 
department  of  the  Cornell  Medical  College  for  several  years.  A 
comparison  of  the  results  secured  by  means  of  cultural  methods  and  by 
the  complement-fixation  tests  in  the  same  cases  indicating  the  degree 
of  reliability  of  the  two  methods  is  given  under  "  Complement-fixation 
Test." 

Collection  of  Material  for  Examination. — The  patient  is  requested  to 
appear  at  the  laboratory  with  a  full  bladder.  After  wiping  the  urethral 
meatus  and  end  of  the  penis  with  an  aqueous  solution  of  carbolic  acid 
(1  to  60),  followed  by  alcohol  (50  per  cent.),  the  patient  is  instructed 
to  empty  the  bladder  completely.  The  first  portion  passed  is  collected 
in  large  sterile  test-tubes  and  is  treated  as  indicated  below.  The 
main  object  of  this  step  in  the  procedure  is  to  mechanically  sterilize 
the  urethral  canal.  A  sterile  dressing  is  now  applied  to  the  end  of  the 
penis  and  after  the  lapse  of  thirty  minutes  the  prostate  and  seminal 
vesicles  are  thoroughly  massaged,  the  meatus  is  again  sterilized  and 
the  urine  passed  is  collected  in  a  sterile  test-tube  of  large  size. 
Material  from  both  samples  of  urine  is  now  transferred  to  sterile  centri- 
fuge tubes  and  centrifugated  at  high  speed  for  fifteen  minutes.  If  the 
amount  of  sediment  secured  by  these  means  is  small,  pour  off  the  clear 
supernatant  fluid,  add  more  urine,  and  repeat  centrifugation.  The 
sediment  thus  obtained  is  employed  for  the  preparation  of  films,  which 
are  stained  with  methylene  blue  in  the  usual  manner.  The  number  of 
bacteria  found  in  the  films  determines  the  amount  of  material  employed 
for  cultural  purposes.  In  addition  three  films  from  each  sample  are 
prepared  and  stained  according  to  the  Gram  method. 

Cultural  Methods. — For  the  initial  cultivation  of  the  gonococcus, 
Wertheim's  ascitic  agar  is  employed.  This  consists  of  2  parts  of  2 
per  cent,  agar  prepared  according  to  standard  methods  and  1  part  of 
ascitic  fluid.  Since  not  all  samples  of  ascitic  fluid  are  equally  suitable 
for  this  purpose  it  is  necessary  to  test  each  new  lot  of  fluid  with  different 
gonococcus  strains  with  a  view  of  determining  this  point. 

Seven  plates  are  poured  in  the  usual  manner.  When  solid,  one  set 
of  three  plates  is  stroked  with  sterile  human-blood  serum  or  defibrinated 
human  blood  which  has  been  allowed  to  age  for  one  week,  with  a  view 
of  destroying  its  normal  bactericidal  properties.  Three  ascitic  agar 
plates  are  now  stroked  consecutively  with  the  sediment  without 


296  IM'ECTIONS  OF    URETHRA   AXD   J'h'OXTATE 

recharging  the  spatula.  The  second  set  of  plates  previously  stroked 
with  human  blood  is  similarly  treated.  Finally,  one  plate  is  inoculated 
with  the  human  blood  employed  for  enriching  purposes  to  establish 
the  sterility  of  this  material.* 

After  twenty-four,  forty-eight  and  seventy-two  hours'  incubation 
the  plates  are  examined  and  suspicious  colonies  consisting  of  Gram- 
negative  cocci  are  transferred  to  ascitic  agar  tubes. 

The  colonies  of  the  gonococcus  are  quite  characteristic.  For 
further  identification  the  organisms  recovered  from  the  plates  are 
grown  on  glucose  and  maltose  agar  free  from  meat-sugar  and  prepared 
in  such  a  manner  as  to  av oid  cleavage  of  the  maltose.  The  gonococcus 
ferments  (with  acid  production)  glucose  only,  which  serves  to  dis- 
tinguish it  from  other  pathogenic  Gram-negative  cocci. 

Serological  methods,  agglutination  tests,  and  complement-fixation 
tests  may,  as  a  rule,  be  dispensed  with. 

NOTE. — The  collection  of  material  may  be  undertaken  by  the 
surgeon,  in  which  case  the  urine  must  be  kept  at  body  temperature 
and  immediately  transported  to  the  laboratory.  Chilling  of  the 
samples  reduces  the  chances  of  success.  On  the  other  hand,  prolonged 
exposure  to  body  temperature  permits  the  growth  of  other  contaminat- 
ing organisms  of  normal  inhabitants  of  the  urethral  canal  wrhich 
renders  the  isolation  of  the  gonococcus  more  difficult. 

The  Complement-fixation  Test. — Schwartz  and  McNeil10  published 
their  first  article  on  the  complement-fixation  test  in  1911.  They  say: 
"  The  chief  point  of  departure  from  the  methods  of  previous  investi- 
gators in  this  line  has  been  in  the  use  of  many  different  strains  of 
gonococci  in  the  preparation  of  the  antigen,  instead  of  only  one.  We 
were  led  to  do  this  by  the  knowledge  that  different  strains  of  the 
gonococcus  seemed  to  differ  considerably  one  from  another,  and  the 
possibility  suggested  itself  that  perhaps  the  serum  of  a  patient  infected 
with  one  strain  of  the  gonococcus  might  only  fix  complement  in  the 
presence  of  an  antigen  from  the  same  strain,  or  from  some  closely 
allied  strains,  but  might  not  do  so  in  the  presence  of  an  antigen  pre- 
pared from  some  widely  separated  strain.  In  case  we  proved  this 
point  wre  realized  that  the  method  would  be  too  cumbersome  for  clinical 
application  if  all  of  the  sera  had  to  be  tested  against  separate  antigens 
prepared  from  a  number  of  different  strains  of  gonococci. 

"  The  idea  occurred  to  us  that  possibly  an  antigen  prepared  from  a 
mixture  of  all  the  different  strains  might  wTork  satisfactorily;  in  other 
wwds,  that  a  '  polyvalent'  antigen  might  detect  the  presence  of  gono- 
coccal  antibodies  every  time  that  a  single  strain  would  do  so." 

(For  the  preparation  of  the  antigen  and  serological  methods  consult 
their  article.) 

To  Keyes5  is  due  the  first  careful  comparison  between  the  relative 
merits  of  the  complement-fixation  test  and  a  careful  bacteriological 
test.  In  his  series  "complement-fixation  test  has  been  found  wrong 

*  These  data  have  been  very  kindly  supplied  by  Prof.  Elser,  of  Cornell. 


THE  GONOCOCCUS  297 

in  1  examination  out  of  47;  bacteriological  test,  1  in  over  100  examina- 
tions." 

Cases  Used  In.  —  McNeil8  says:  "In  cases  of  anterior  gonorrheal 
urethritis  in  the  male,  and  acute  vulvovaginitis  in  the  female,  a  positive 
reaction  is  practically  never  obtained.  But  shortly  after  the  posterior 
urethra  in  males,  and  the  cervix  and  the  glands  of  Bartholin  in  females 
are  involved  the  same  patient  reacts  positively." 

The  complement-fixation  test  is,  therefore,  sooner  or  later  positive 
in  cases  (in  the  male)  of  posterior  urethritis,  prostatitis,  seminal  vesicu- 
litis,  epididymitis,  cystitis,  pyelonephritis,  arthritis,  etc. 

Time  of  Appearance. — A  positive  reaction  in  the  blood  may  not  be 
looked  for  until  the  gonococci  have  persisted  long  enough  to  cause 
such  a  reaction :  this  usually  takes  about  a  month.  "  I  have  obtained 
a  reaction  in  twelve  days."  (Keyes.) 

Time  of  Disappearance. — "A  positive  reaction  usually  persists  from 
six  to  eight  weeks  after  a  cure  has  been  effected.  It  has  also  been 
found  that  antibodies  disappear  from  the  blood  of  rabbits  immunized 
to  gonococci  in 'about  the  same  period.  Therefore,  if  a  strong  positive 
reaction  is  obtained  seven  or  eight  weeks  after  a  probable  cure,  the 
patient  should  be  treated  as  if  he  still  harbored  gonococci."  (McNeil.) 
A  negative  reaction  has  been  obtained  two  weeks  after  cure. 

Effect  of  Vaccines  of  Complement-fixation  Test. — If  gonococcus  vac- 
cines are  given  to  a  patient  who  has  a  fading  or  weakly  positive 
complement-fixation  test,  the  vaccines  will  change  this  weakly  positive 
to  a  strongly  positive  test. 

If  a  patient  has  not  recently  had  a  gonorrhea,  the  giving  of  vaccines 
will  affect  his  complement  not  at  all.* 

It  is  possible  that  vaccines  given  to  a  patient  whose  complement- 
fixation  test  has  recently  become  negative  might  change  this  negative 
into  a  positive  complement-fixation  test.  If  this  be  so,  its  medico- 
legal  value  is  obvious. 

Vaccines  given  to  animals  cause  a  complement-fixation  test  to  per- 
sist for  about  fifty  days.  It  is  probable  that  this  is  a  good  index  for 
the  time  of  persistance  in  man. 

Weakly  Positive  Complement-fixation  Tests. — As  far  as  my  experience 
goes  a  complement-fixation  test  either  weak  or  strong  is  caused  alone 
by  gonococcal  inflammation. 

A  weakly  positive  complement-fixation  test  is  interpreted  as  meaning 
that  a  gonorrhea  is  nearly  or  already  cured.  It  should,  however,  be 
interpreted  in  relation  to  the  clinical  symptoms.  If  the  clinical  symp- 
toms are  at  variance  with  the  weakly  positive  test,  then  another 
complement-fixation  test  should  be  made  after  a  period  of  some  weeks 
or  a  culture  should  be  the  final  test  of  cure. 

I  do  not  believe,  however,  that  I  have  ever  seen  a  weakly  positive 
complement-fixation  test  become  strongly  positive  (if  vaccines  are  not 
given)  or  a  weakly  positive  do  anything  else  than  become  rapidly 
negative. 

*  Schwartz  is  my  authority  for  these  two  statements. 


298  INFECTIONS  OF   URETHRA  AND  PROSTATE 

Practical  Value. — In  all  cases  of  anterior  gonorrhea  a  clear  urine  or  a 
bacteriological  test  are  necessary  to  declare  a  patient  cured.  In  all 
cases  of  posterior  urcthritis  I  have,  with  very  few  exceptions,  used  the 
complement-fixation  test  alone.  Its  results,  of  course,  must  be  inter- 
preted with  discretion.  If  a  patient  have  a  general  arthritis,  and  a 
complement-fixation  test  pronounces  this  gonorrheal  in  origin,  gono- 
cocci  are  not  necessarily  present  in  the  urethra.  In  case  of  differential 
diagnosis  between  rheumatoid  arthritis  and  gonorrheal  arthritis  the 
complement-fixation  test  fixes  the  diagnosis.  Naturally,  the  comple- 
ment-fixation is  negative  if  an  arthritis  is  due  to  a  non-gonorrheal 
seminal  vesiculitis. 

Keyes  has  pointed  out  its  value  in  solving  certain  medicolegal 
problems. 

"A  married  man  had  acquired  a  gonorrhea  several  months  pre- 
viously and  had  infected  his  wife.  No  gonococci  were  found  in  the 
urine,  and  he  was  declared  free  from  infection,  although  his  urethritis 
was  not  cured.  His  wife  was  also  examined  and  pronounced  cured. 
No  blood  test  was  made  upon  either.  Yet  six  months  later  he  returned, 
denying  extramarital  exposure,  but  showing  a  fresh  gonorrhea  two 
weeks  old.  Both  he  and  his  wife  immediately  submitted  to  the 
complement-deviation  test,  and  both  were  negative.  Four  weeks  later 
he  was  positive  and  she  negative,  while  she  remained  clinically  clean. 
This  development  of  a  positive  reaction  in  him  showed  his  infection  to 
be  a  fresh  one  due  to  extramarital  exposure,  in  spite  of  his  fervent 
denials." 

The  accuracy  of  the  complement-fixation  test  varies  according  to  the 
experience  of  the  serclogist  in  doing  the  test. 

If  a  serologist  has  but  recently  taken  up  the  test,  his  results  should 
be  checked  up  by  comparison  with  the  clinical  and  bacteriological 
findings.  And  even  if  performed  by  a  serologist  experienced  in  doing 
the  test,  a  similar  checking  up  should  take  place  from  time  to 
time. 

Etiology  of  Gonorrheal  Urethritis. — This  disease  is  practically  always 
acquired  by  coitus  on  the  part  of  the  male  with  a  woman  infected  with 
gonorrhea.  One  who  treats  gonorrhea  should  be  acquainted  with  vari- 
ous peculiarities  in  its  transmission,  because  the  afflicted  male  always 
wishes  to  place  the  blame  for  his  disease;  wishes  to  know  why  he  has 
acquired  it;  and  why  another  male  friend,  possibly  the  husband,  is 
free  from  it. 

Wertheim  says  husband  and  wife  may  become  so  immune  to  each 
other's  gonococci  that  it  is  impossible  to  have  a  further  exacerbation  of 
the  disease  between  these  two.  When  a  third  person  trespasses,  how- 
ever, he  may  acquire  an  acute  gonorrhea,  while  neither  of  the  original 
pair  have  any  manifestations  of  the  disease. 

The  male  may  have  used  a  protector  (condom).  "Such  a  gonorrhea 
is  acquired  during  preliminary  skirmishing." 

Ci^e  of  two  men  who  have  connection  with  the  same  woman  may 
acquire  gonorrhea  and  the  other  not.  Difference  in  the  conformation 


THE  GONOCOCCUS  299 

of  the  urethral  meatus  may  have  caused  this;  a  wide  meatus  predis- 
poses. Also  one  may  have  been  intoxicated,  which  also  favors  the 
acquisition.  It  is  well  to  remember  that  a  medical  certificate  alleging 
freedom  of  the  woman  from  gonorrhea  means  nothing.  Such  certifi- 
cates are  generally  given  by  physicians  who  are  incompetent  and 
untrustworthy.  Such  a  certificate  may  antedate  the  present  gonor- 
rhea. It  is  probable  that  the  female  is  infectious  at  times  and  at  other 
times  uninfectious;  for  example,  the  local  congestion  due  to  menstrua- 
tion may  bring  forth  the  hidden  goriococcus. 

Pathology  of  Acute  Gonorrhea!  Urethritis. — Acute  Anterior  Gonorrhea. 
— Our  knowledge  of  this  dates  to  the  wrork  of  Finger,  Gohm,  and 
Schlagenhaufer2  who  inoculated  criminals  condemned  to  death  and 
then  found  by  an  immediate  postmortem  the  changes  caused  by  the 
gonoccocus.  Keyes  sums  up  their  work  as  follows: 

"Thirty-eight  hours  after  inoculation  the  gonococci  had  only  just 
begun  to  effect  an  entrance  between  the  epithelial  cells.  The  lacunae  of 
Morgagni  were  crowded  with  the  cocci ;  diapedesis  had  begun  and  intra- 
cellular  gonococci  were  found  among  the  few  leukocytes  on  the  surface 
of  the  epithelium.  At  the  end  of  three  days  the  inflammatory  process 
was  well  under  way.  The  surface  of  the  mucous  membrane  was  covered 
with  pus,  its  epithelium  infiltrated  by  bacteria  from  one  side  and  by 
leukocytes  from  the  other.  The  inflammation  showed  four  striking 
characteristics,  viz. :  (1)  The  pavement-epithelium  of  the  fossa  navic- 
ularis,  although  swollen  with  leukocytes,  resisted  the  invasion  of  the 
gonococci  almost  absolutely ;  (2)  the  cylindrical  epithelium  of  the  penile 
urethra  was  generally  invaded;  (3)  this  invasion  was  most  marked 
about  the  crypts  and  glands,  which  were  packed  with  pus  and  gonococci; 
(4)  the  subepithelial  connective  tissue,  though  showing  every  evidence 
of  inflammation,  contained  few  gonococci  except  in  the  neighborhood 
of  the  crypts  and  glands." 

The  inflammation  extends  until  gonococci  have  penetrated  deep  into 
the  layers  of  the  mucous  membrane,  which  has  become  acutely  con- 
gested, the  epithelium  undergoing  mucous  degeneration  and  exfoliating 
in  patches.  Later  the  mucosa  is  occupied  by  embryonic  cells,  becomes 
thick,  inelastic,  and  bleeds  easily.  The  inflammation  may  extend 
beyond-  the  mucosa  to  the  submucous  layer  and  even  to  the  corpora 
cavernosa.  This  may  be  accompanied  by  phlebitis,  arteritis,  or 
lymphangitis. 

The  ducts  of  many  of  the  urethral  glands  and  crypts  are  inflamed. 
The  inflammation  in  the  ducts  may  simply  resolve  or  the  inflammation 
may  cause  closure  of  the  orifices  of  the  ducts  and  extend  into  the  glands, 
which  may  be  converted  into  pus  sacs.  Such  an  abscess  cavity  may 
discharge  through  the  gland  duct  into  the  urethra  or  rupture  directly 
through  the  mucous  membrane;  or  the  gland  may  enlarge  and  finally 
rupture  externally  through  the  corpus  spongiosum. 

In  most  cases,  if  the  patient  be  properly  treated,  or  at  least  let  alone, 
the  inflammation  travels  slowly  toward  the  posterior  part  of  the  anterior 
urethra,  the  gonococcus  diminishing  in  virulence  the  while.  The 


:;oo  INFECTIONS  <>r  URETHRA  AND  PROSTATE 

inflammation  may  be  restricted  to  the  anterior  urethra  and  never  reach 
the  posterior. 

Acute  Posterior  (Gonorrhea. — In  most  cases,  however,  the  gonorrhea 
does  reach  the  posterior  urethra,  sometimes  stormily,  sometimes  quietly. 
These  stormy  invasions  are  generally  the  result  of  improper  and  too 
early  instrumentation  or  indiscretions  on  the  part  of  the  patient;  rarely 
to  a  virulent  infection. 

By  the  time  the  gonococci  reach  the  posterior  urethra  their  virulence 
is  generally  diminished  and  the  body  lias  been  manufacturing  antibodies 
for  some  days.  So  the  posterior  urethra  may  be  acutely  inflamed,  or 
attacked  by  somewhat  enfeebled  gonococci,  which  results  in  a  more  or 
less  subacute  inflammation. 

Almost  every  posterior  urethritis  involves  both  the  membranous  and 
prostatic  urethra.  The  glands  of  the  membranous  urethra  are  few  and 
inflammation  of  this  portion  is  always  overshadowed  by  the  prostatic 
involvement.  The  verumontanum  may  be  acutely  inflamed  and  the 
inflammation  may  travel  to  the  seminal  vesicles  or  by  way  of  the 
seminal  ducts  to  the  epididymis.  Acute  epididymitis  is  commoner 
than  acute  seminal  vesiculitis. 

Pathology  of  Acute  Gonorrhea!  Prostatitis. — Acute  prostatitis  is  of 
three  different  grades. 

1.  Catarrhal  prostatitis  probably  occurs   in   all   cases  of  posterior 
gonorrhea;  the  gonococcus  enters  the  prostatic  ducts  and  causes  a  pro- 
liferation and  desquamation  of  epithelium  and  leukocytes.    This  may 
resolve  or  become  chronic. 

2.  Follicular  prostatitis  is  more  infrequent  than   catarrhal.     The 
gonococcus  enters  a  prostatic  duct  and  causes  a  purulent  inflammation. 
The  walls  swell  and  the  mouth  of  the  duct  is  blocked  with  pus ;  a  small 
abscess  forms  which  breaks  through  the  duct  or  through  the  surface  of 
the  gland. 

3.  Parenchymatous  Prostatitis. — All  parts  of  the  prostate  are  affected; 
the  glands  may  be  primarily  so,  and  the  fibromuscular  stroma  second- 
arily involved. 

There  is  marked  congestion  and  serous  infiltration ;  then  small  round- 
celled  infiltration  with  enlargement  of  the  gland.  This  form  may 
resolve  completely,  but  it  often  goes  on  to  chronic  induration  and  leaves 
an  enlarged  prostate.  The  most  severe  form  is  purulent  inflammation 
with  abscess  formation,  when  a  half  or  all  of  the  prostate  may  become 
a  pus  sac.  This  may  break  into  the  urethra,  or  into  the  rectum, 
or  appear  in  the  perineum,  or  ischiorectal  fossa.  A  periprostatic 
abscess  may  follow  a  prostatic  abscess.  We  may  have  finally 
periprostatic  phlebitis,  which  may  cause  thrombosis  and  metastatic 
abscesses. 

Urinary  infiltration  with  gangrene  of  the  perineum  and  gangrene  of 
the  penis,  because  of  compression  and  thrombosis  of  the  "plexus  pubes 
impar,"  may  occur. 

Pathology  of  Cowperitis. — Acute  inflammation  of  Cowper's  glands 
follows  the  same  grades  of  inflammation  as  are  seen  in  the  prostate. 


THE  GONOCOCCUS  301 

If  an  abscess  of  Cowper's  glands  forms,  it  generally  points  in  the  peri- 
neum on  either  side  of  the  bulb. 

Pathology  of  Chronic  Gonorrheal  Urethritis. — The  acute  inflammation 
generally  passes  over  into  the  subacute  and  chronic  forms  within  a 
few  weeks.  The  discharge  and  gonococci  diminish.  The  embryonic 
infiltrations  are  resorbed  and  the  epithelium  is  gradually  regenerated, 
but  probably  in  no  case  are  the  cylindrical  epithelial  cells  restored  as 
such.  In  their  place  is  put  down  pavement-epithelium.  Gonococci 
do  not  attack  pavement-epithelium  as  readily  as  they  do  cylindrical, 
which  accounts  for  the  severity  of  the  first  gonorrhea  and  comparative 
mildness  of  future  attacks.  Aside  from  the  above  the  urethra  may 
return  to  normal.  With  subsequent  inflammations  or  with  a  severe  and 
long  first  gonorrhea,  this  pavement-epithelium  may  be  replaced  by 
flat  squamous  epithelium  which  still  further  resists  the  entrance  of  the 
gonococcus. 

Gonorrhea  becomes  chronic  because  the  inflammation  persists  in 
glands  and  crypts  of  the  urethra.  The  glands  of  Littre  may  become 
small  pus  sacs  because  of  occluded  ducts;  these  sacs  may  rupture  and 
the  gland  become  obliterated,  filled  with  scar  tissue;  or  they  may  be 
converted  into  cysts.  The  crypts  may  become  reddened.  The 
mucosa  because  of  the  chronic  inflammation  may  lose  its  grayish-yel- 
low color  and  its  strise  and  become  red.  (Soft  infiltration  of  Oberlander.) 

\Vith  the  progress  of  the  inflammation  this  redness  may  change 
to  a  grayish  color  because  sclerosis  of  the  bloodvessels  and  that  part 
of  the  urethra  become  a  more  or  less  rigid  tube.  In  places  the 
caliber  of  the  tube  may  be  encroached  upon.  There  may  be  papillary 
growths  and  granulating  areas.  This  is  the  hard  infiltration  of  Ober- 
lander, which  is  the  beginning  of  stricture  formation  and  is  most  often 
seen  in  the  anterior  urethra.  Stricture  of  the  posterior  urethra  is 
relatively  rare. 

Pathology  of  Chronic  Prostatitis. — Chronic  prostatitis  may  follow 
an  acute  prostatitis  but  it  usually  begins  insidiously,  and  gives  rise  to 
but  few  symptoms  in  its  early  stage.  Most  cases  are  gonorrheal  or 
postgonorrheal  in  origin.  Masturbation  and  sexual  excesses  are  factors 
in  its  cause.  Cystitis  and  even  pyelonephritis  sometimes  are  accom- 
panied by  a  prostatitis. 

Various  bacteria  are  found  in  the  prostatic  secretion,  from  the 
gonococcus  and  streptococci,  staphylococci,  and  colon  bacilli. 

The  glands  of  the  prostate  show  proliferation  and  desquamation  of 
epithelium,  and  their  lumen  occluded  by  pus  and  epithelium.  Later 
there  is  periglandular  round-celled  infiltration.  Sclerosis  and  contrac- 
tion of  the  new  tissue  takes  place  and  causes  destruction  of  glandular 
tissue  or  dilatation  from  obstruction  of  the  gland  ducts.  The  gland 
may  therefore  feel  small  and  firm  or,  more  often,  enlarged  with  soft, 
"mushy"  spots.  Sometimes  there  are  small  points  of  suppuration 
throughout  the  prostate. 

Pathology  of  the  Seminal  Vesicles. — Belfield  was  the  first  to  get 
radiographs  of  both  normal  and  diseased  seminal  vesicles.  Through  a 


302  IXFECTIOXX  OF    URETHRA   AXD   PROSTATE 

cut  in  the  vas  he  filled  the  vesicle  with  collargol  and  then  took  radio- 
graphs. Cabot,  Barney  and  others  have  done  likewise.  It  is  diffi- 
cult to  say  what  percentage  of  posterior  gonorrheas  affect  the  seminal 
vesicles.  Caulk*  says  "That  90  per  cent,  of  gonorrheas  became 
posterior  and  that  90  per  cent,  of  these  cause  involvement  of  the 
seminal  vesicles."  If  the  seminal  vesicles  are  involved  by  the  gonor- 
rheal  inflammation,  then  the  processes  maybe  acute,  subacute  or  chronic. 
Because  of  the  convoluted  tubules  of  the  vesicle  and  the  small  urethra! 
exit,  cure  of  the  condition  is  often  very  difficult.  In  acute  infections, 
which  are  almost  invariably  caused  by  the  gonococcus,  we  may  have 
obstruction  of  the  ducts,  abscess  formation,  perivesicular infiltration,  etc. 
This  inflammation  may  result  in  the  pus  emptying  through  the  main 
duct  into  the  urethra  or  it  may  become  subacute  or  chronic;  or  the  pus 
sac  may  rupture  into  the  ischiorectal  fossa,  rectum,  or  peritoneal 
cavity.  The  gross  pathology  of  chronic  inflammatory  lesions  of  the 
seminal  vesicles  is  quite  variable.  They  may  be  large,  firm,  and 
distended  with  obstructed  ducts  and  abscess  formation.  There  is 
apt  to  be  a  perivesicular  infiltration,  so  that  one  may  not  be  able  to 
outline  the  confines  of  the  vesicle  because  of  their  being  matted  down 
with  a  plastic  exudate.  In  fact,  operative  experience  in  acute  seminal 
vesiculitis,  in  which  the  rectal  touch  has  seemingly  demonstrated 
swollen  vesicles  and  supposed  abscesses,  has  shown  that  the  vesicles 
in  such  cases  are  not  distended  with  pus  but  the  process  is  usually  one 
of  perivesicular  infiltration.  In  the  chronic  process  gonococci  are 
rarely  found.  Staphylococci,  streptococci,  colon  and  tubercle  bacilli, 
and  various  other  unclassified  bacilli  have  been  isolated.  Not  infre- 
quently sterile  cultures  are  obtained  from  the  seminal  fluid.  Cabot 
and  Barney  found  that  the  perivesical  adhesions  were  most  frequent 
at  the  lower  end  of  the  vesicle  and  the  vas,  and  that  if  one  vesicle  is 
involved,  its  fellow  "may  be  safely  accused."  Caulk  says  that  "the 
seminal  vesicle  bears  an  important  pathological  significance  also  on 
account  of  its  proximity  to  the  ureter.  Young,  Squier,  and  Yoelcker 
have  reported  cases  of  renal  infection  due  to  ureteral  stricture  second- 
ary to  the  vesicular  infiltration." 

Symptoms  of  Acute  Anterior  Genorrheal  Urethritis. — Incubation. — The 
limits  of  this  period  are  two  and  twelve  days;  oftener  five  to  seven 
days.  (Experimental  inoculation  produces  a  discharge  on  the  second, 
third,  fourth  and  fifth  days.)  A  non-gonorrheal  urethritis  occurring 
in  a  damaged  urethra  and  caused  by  sexual  strain,  excessive  alcohol, 
etc.,  often  has  a  very  short  incubation,  say  twenty-four  hours.  So  also 
an  acute  exacerbation  of  a  chronic  gonorrhea.  A  long  foreskin  may 
mask  the  discharge  for  some  days. 

Invasion. — If  a  patient  is  intelligent,  he  generally  notices  the  early 
symptoms  of  gonorrhea,  itching,  tickling,  or  burning  in  the  meatus. 
If  unintelligent,  he  often  delays  his  visit  to  the  physician  until  the 
tickling  has  become  (on  the  second  or  third  day)  a  vigorous  burning 

*  Caulk1  has  written  a  very  complete  review  of  the  "Surgery  of  the  Seminal  Vesicles, 
and  their  Ducts."  I  have  closely  followed  and  quoted  from  this  review. 


303 

on  urination  along  the  course  of  the  anterior  urethra  and  a  urethral 
discharge  has  become  established.  Or  the  patient's  attention  may 
have  been  attracted  by  the  red  and  swollen  meatus  which  accompanies 
the  discharge.  The  inflammation  may  reach  its  height  very  early 
(in  a  few  hours),  or  late  (a  number  of  days) .  The  factors  which  modify 
the  attack  are  the  vigor  of  the  strain  of  gonococcus  with  which  the 
patient  is  affected;  the  natural  or  acquired  immunity  of  the  patient 
(acquired  by  previous  attacks  of  gonorrhea),  the  age  of  the  patient 
(boys  and  old  men  are  prone  to  severe  attacks) ,  and  the  treatment. 

Local  Symptoms. — When  the  attack  has  reached  its  height,  there  are 
four  cardinal  local  symptoms:  discharge,  burning  on  urination,  red 
meatus,  and  painful  erections. 

The  discharge  is  formed  of  the  products  of  the  inflammation,  pus, 
epithelial  cells  and  gonococci.  It  is  at  first  mucoid,  then  rapidly 
changes  to  typical  thick,  yellowish  pus.  Later  it  loses  its  yellow  color 
and  again  becomes  mucoid.  The  discharge  varies  in  quantity  accord- 
ing to  the  severity  of  the  inflammation  and  the  period  of  time  between 
urinations.  When  the  patient  urinates,  the  urethra  is  washed  fairly 
free  of  pus.  The  discharge  is  usually  greatest  in  the  morning  because 
of  the  long  interval  without  urination.  It  may  be  tinged  with  blood. 

Burning  on  Urination. — The  acid  urine  passing  over  the  inflamed 
urethra  causes  pain.  This  pain  is  an  index  of  the  acuteness  of  the 
attack,  and  may  be  very  severe  or  inconsequential. 

The  red  and  swollen  meatus  is  the  index  of  the  condition  of  the 
anterior  urethra  in  acute  gonorrhea.  It  is  the  main  differential  point 
between  a  new  infection  and  an  exacerbation  of  an  old  gonorrhea. 
In  the  latter  the  infection  comes  from  the  posterior  urethra,  and  when 
it  reaches  the  anterior  it  is  in  a  subacute  stage,  which  accounts  for  the 
absence  of  an  inflamed  meatus.  Reinfections  run  a  much  milder 
course  than  new  infections,  and  naturally  are  liable  to  be  more  chronic. 

Painful  erections  are  due  to  the  stretching  of  a  rigid  and  inflamed 
urethra.  Normally  the  urethra  is  elastic  and  easily  distensible. 
The  inflamed  urethra  may  be  so  rigid  and  fixed  that  when  the  corpora 
cavernosa  distend  on  erection  the  penis,  as  a  whole,  may  curve  down- 
ward. This  is  known  as  chordee,  and  often  causes  excruciating  pain 
and  perhaps  bleeding. 

Variations  in  Attacks. — The  above  describes  a  typical  attack.  There 
may  be  all  grades  of  infection,  from  an  attack  in  which  the  one  symptom 
is  urethral  discharge,  which  contains  gonococci,  to  a  hyperacute  attack 
which  rapidly  invades  the  posterior  urethra. 

General  symptoms  are  often  present  in  a  mild  degree.  Lassitude, 
slight  temperature,  loss  of  appetite,  and  possibly  chills  may  accompany 
the  attack. 

Urine  Changes. — Urine  running  from  the  bladder  reservoir  over  a 
urethra  covered  with  pus  washes  off  that  pus  so  that  when  the  urine 
is  passed  it  contains  pus  cells  in  suspension.  This  causes  the  urine 
to  become  more  or  less  cloudy;  or  if  there  is  no  free  pus  but  only 
shreds  of  pus  in  the  urethra,  the  urine  is  clear,  with  the  shreds  floating 


304  IXFECTIOXS  OF   URETHRA   AXD  PROSTATE 

in  it.  Because  of  these  facts,  and  because  the  urethra  is  divided  into 
an  anterior  and  posterior  part,  various  tests  have  been  suggested  to 
determine  by  the  examination  of  the  urine  the  source  of  the  pus  and 
shreds. 

The  two  tests  most  in  use  are  Thompson's*  two-glass  test  and 
Kollman's  five-glass  test. 

Using  the  two-glass  test  the  first  glass  is  cloudy  while  the  second  is 
clear,  although  the  .first  two  may  be  cloudy  if  the  discharge  is  very 
profuse. 

Diagnosis. — The  diagnosis  is  principally  between  non-gonorrheal 
urethritis  (p.  334)  and  an  acute  exacerbation  of  an  old  gonorrhea.  In 
the  latter  the  short  incubation,  the  lack  of  a  red  meatus,  the  history, 
and  the  presence  of  a  posterior  urethritis  (pus  in  the  prostate)  generally 
clinch  the  diagnosis. 

Course. — An  acute  anterior  urethritis  may  resolve  or  become  a 
chronic  anterior  urethritis.  More  likely  it  is  complicated  by  an  acute 
or  subacute  posterior  urethritis. 

Complications  of  Acute  Anterior  Gonorrhea. — These  are  abscess  of  the 
urethral  glands,  peri-urethritis  and  peri-urethral  abscess,  balanoposthi- 
tis,  lymphangitis  and  adenitis,  and  inflammation  of  the  erectile  tissue. 

Abscess  of  Urethral  Glands,  Peri-urethritis  and  Peri-urethral  Abscess. 
— Any  of  the  urethral  glands  may  be  invaded  by  the  gonococcus,  the  duct 
of  the  glands  plugged  by  the  inflammation  and  the  gland  suppurate. 

*  The  most  popular,  the  simplest  and  perhaps  the  least  accurate  is  the  two-glass  test 
of  Thompson,  viz.:  the  bladder  is  full  of  urine.  The  patient  passes  four  ounces  of  urine 
into  a  first  glass  and  the  remainder  into  a  second  glass.  We  may  then  have  one  of  four 
conditions: 

I.  First  glass  cloudy,   second  glass  clear. 
II.  First  and  second  cloudy. 

III.  First   glass   clear,    second    cloudy. 

IV.  Urine  clear  but  shreds  in  first  or  second,  or  both. 

(It  is  supposed  that  the  cloud  is  due  to  pus.  This  can  definitely  be  determined  by  the 
microscope.  If  the  cloud  is  due  to  phosphates,  acetic  acid  dropped  into  the  urine  will 
clear  it.  If  the  cloud  is  due  to  internally  administered  copaiba,  acetic  acid  will  not  clear 
the  urine.)  In  acute  gonorrhea,  I  means  an  anterior  urethritis  and  no  inflammation 
above  the  cut-off  muscle.  In  chronic  gonorrhea,  I  may  mean  an  anterior  and  posterior 
urethritis.  It  never  means  bladder  or  kidney  pus.  II  generally  means  an  anterior  and 
posterior  urethritis.  It  may  mean  only  an  anterior  urethritis  with  such  a  profuse  dis- 
charge of  pus  that  the  first  four-ounce  wash  of  urine  is  not  enough  to  cleanse  the  urethra 
of  pus.  It  may  mean  bladder  or  kidney  pus.  Ill  means  a  posterior  urethritis.  The 
prostate  laden  with  pus  has  squeezed  this  pus  into  the  urethra  with  the  final  bladder 
squeeze  occurring  at  the  end  of  urination.  IV  may  mean  a  mild  anterior  or  posterior 
urethritis  or  both.  The  two-glass  test  must  be  interpreted  in  conjunction  with  the  symptoms. 
If  there  is  a  conflict  between  the  two,  a  further  test,  the  Kollman,  must  be  made.  Kollman 
Test  Modified:  The  anterior  urethra  is  washed  (using  sterile  water)  with  a  syringe  or 
through  a  small  rubber  catheter  passed  as  far  as  the  bulb.  The  washings  are  continued 
until  the  return  irrigation  is  clear.  The  patient  then  passes  urine  into  a  second  glass 
(four  ounces).  This  represents  posterior  urethral  pus  or  shreds.  The  prostate  is  then 
massaged  and  urine  is  passed  into  a  third  glass,  which  represents  the  prostatic  contents. 
The  fourth  glass  of  passed  urine  represents  pus  coming  from  above  the  prostate  (bladder 
or  kidneys).  I  confess  that  I  rarely  now  use  this  test.  I  also  confess  to  treating  as  a 
chronic  urethritis  a  case  of  tuberculosis  of  the  kidney  for  some  weeks  before  I  suspected 
something  wrong  and  did  a  cystoscopy.  At  present  if  in  doubt  I  always  put  a  catheter 
into  the  bladder  and  carefully  observe  the  washings.  If  the  first  four  or  five  washings 
(two  ounces  each)  are  cloudy  or  persist  in  their  shreddy  contents,  I  then  cystoscopeor 
urethroscope  the  patient. 


THE  GONOCOCCUS  305 

According  to  the  length  of  the  duct  and  the  acuteness  of  the  inflam- 
mation the  abscess  discharges  its  contents  directly  into  the  urethra  or 
through  its  duct  and  so  heals.  The  abscess  often  gives  localized  pain, 
and  if  the  urethra  is  palpated,  can  be  felt  as  a  small  shot-like  mass 
along  the  urethra.  Not  infrequently  these  abscesses  are  multiple  and 
can  be  felt  along  the  entire  pendulous  urethra.  Such  cases  are  often 
very  acute  and  run  a  long  course.  Cases  in  which  there  is  a  suddenly 
increased  urethral  discharge  with  perhaps  reinfection  of  the  urethra 
are  generally  due  to  the  rupture  of  a  urethral  abscess. 

Often  the  abscess  does  not  rupture  into  the  urethra  but  involves  the 
peri-urethral  tissues  and  points  externally.  A  favorite  place  for  such 
an  abscess  is  just  back  of  the  frenum.  Occasionally  an  abscess  can  be 
incised  intra-urethrally  through  an  endoscope.  Generally,  however, 
there  is  a  distinct  space  corresponding  to  the  duct  of  the  gland  between 
the  abscess  and  the  urethra.  Then  the  abscess  points  externally  and 
is  opened  through  a  small  incision.  Healing  is  generally  rapid.  In 
certain  cases,  however,  a  urethral  fistula  is  left  which  requires  opera- 
tion to  close. 

Balanoposthitis. — This  usually  occurs  because  of  a  tight  foreskin 
which  retains  the  gonorrheal  pus.  Sometimes  the  patient  retracts  the 
foreskin  back  of  the  corona  but  cannot  get  it  back.  The  resulting 
paraphimosis  can  often  be  reduced.  If  not,  a  dorsal  incision  has  to 
be  made. 

Lymphangitis  and  Adenitis, — This  is  seen  fairly  often.  The  inflamed 
lymph  channels  can  be  felt  as  hard,  tender  cords  ^extending  along  the 
dorsum  of  the  penis.  Sometimes  an  enlarged  gland  is  also  felt.  Under 
appropriate  treatment  this  readily  subsides.  I  have  never  seen  one 
suppurate. 

Inguinal  adenitis  and  suppuration  of  the  inguinal  glands  are  not 
rare. 

"  Inflammation  -of  the  erectile  tissue,  spongeitis,  and  cavernitis"  are 
extremely  rare  complications  of  gonorrhea,  if  we  except  that  type  of  the 
former  that  manifests  itself  in  chordee."  (Keyes.) 

Symptoms  of  Acute  Posterior  Gonorrheal  Urethritis. — The  membranous 
and  prostatic  urethra,  and  the  prostate  are  always  attacked  in  posterior 
urethral  gonorrhea.  In  most  cases  it  is  probable  that  the  seminal 
vesicles  are  also  attacked.  Whether  or  not  posterior  urethritis  is 
classed  as  a  complication  of  urethral  gonorrhea,  it  is  a  fact  that  in  the 
majority  of  cases  of  gonorrhea  the  posterior  urethra  is  invaded  by  the 
gonococcus.  As  the  posterior  urethra  is  intimately  associated  with  the 
function  of  urination,  acute  inflammation  of  the  posterior  urethra  is 
accompanied  by  disturbances  of  urination. 

The  patient  gives  a  history  of  a  preceding  anterior  urethritis,  or  if 
the  acute  posterior  urethritis  is  an  exacerbation  of  an  old  posterior 
gonorrhea,  then  the  history  of  this. 

Frequency  of  Urination. — The  patient  generally  has  increased  fre- 
quency, particularly  at  night.  He  may  arise  once  at  night,  or  in  a 
severe  attack  he  may  urinate  as  often  as  every  fifteen  minutes,  day  and 

M  u    i—20 


INFECTIONS  OF   URETHRA  AND  PROSTATE 

night;  he  may  have  increased  pain  on  urination;  or  pain  particularly 
at  the  end  of  urination,  caused  by  the  closing  down  of  the  sphincter  on 
the  inflamed  prostatic  urethra;  this  pain  may  be  in  the  perineum, 
hypogastrium,  in  the  rectum,  at  the  end  of  the  penis  or  along  the 
urethra.  For  the  same  reason  he  may  possibly  have  a  terminal 
hematuria. 

Urinary  Changes. — Using  the  two-glass  test  the  second  urine  is 
cloudy. 

Course. — Acute  posterior  gonorrhea  remains  at  its  height  from  a  num- 
ber of  days  to  a  week,  and  then  all  the  symptoms  may  gradually  sub- 
side until  the  patient  is  left  with  a  slight  urethral  discharge,  generally 
in  the  form  of  a  "morning  drop"  (chronic  gonorrhea),  or  one  of  a 
number  of  complications  may  set  in. 

Complications  of  Acute  Posterior  Gonorrhea. — These  are  cowperitis, 
prostatic  abscess,  seminal  vesiculitis,  epididymitis,  (see  p.  300),  cystitis, 
(see  p.  301),  pyelonephritis,  peritonitis. 

Cowperitis. — \Ye  generally  say  that  an  abscess  originating  on  either 
side  of  the  membranous  urethra  is  due  to  an  abscess  of  Cowper's  glands. 
Such  an  abscess  is  rarely  diagnosed  when  small,  probably  because  of 
the  infrequence  with  which  we  try  to  palpate  Cowper's  glands.  Gen- 
erally, when  a  diffuse  abscess  appears  on  one  or  both  sides  of  the  bulb 
(if  stricture,  prostatic  abscess,  and  ischiorectal  abscess  can  be  excluded), 
we  attribute  such  an  abscess  to  a  cowperitis.  The  deep  layer  of  the 
perineal  fascia  prevents  an  abscess  originating  in  Cowper's  glands  from 
traveling  backward,  which  accounts  for  its  appearance  in  the  perineum. 
Luys  reports  two  cases  in  which  a  more  or  less  chronic  cowperitis  was 
diagnosed  by  palpating  the  enlarged  Cowper's  glands  and  expressing 
(intra-urethrally)  the  pus  therefrom. 

The  cure  consisted  in  massage  of  the  glands  and  irrigation  and  dila- 
tation of  the  urethra.  Generally,  however,  the  abscess  points  exter- 
nally and  either  ruptures  or  is  incised. 

Prostatic  Abscess. — The  division  line  between  acute  prostatitis  and 
prostatic  abscess  is  hard  to  draw.  A  patient  may  have  only  the  symp- 
toms of  a  posterior  urethritis  and  yet  may  have  a  small  superficial 
prostatic  abscess  which  makes  itself  known  by  rupturing  into  the 
urethra  and  relief  in  the  patient's  symptoms.  As  a  rule,  however,  a 
prostatic  abscess  of  any  magnitude  involving  a  part  of  one  or  both  lobes 
of  the  prostate  gives  the  following  symptoms : 

1.  It  occurs  in  the  course  of  an  acute  or  subacute  gonorrhea. 

2.  The  symptoms  of  the  preceding  posterior  urethritis,  dysuria,  pain 
and  frequency  become  worse.     If  there  be  only  an  antecedent  acute 
anterior  urethritis  and  the  prostatic  abscess  is  the  result  of  an  over- 
whelming infection,  the  dysuria,  pain,  and  frequency  begin  intensely. 
The  pain  of  the  acute  prostatitis,  referred  generally  to  the  region  of  the 
prostate,  is  surprisingly  acute  and  tenacious.     I  remember  one  patient 
with  an  acute  parenchymatous  prostatitis  who  had,  for  nearly  two 
weeks,  an  intensely  acute  pain  "like  a  hot  coal"  in  his  prostate.     He 
could  not  sit  down — particularly  on  a  cushion;  hard  surfaces  seemed 


THE  GONOCOCCUS  307 

best  adapted  for  sitting — and  his  pain  was  only  controlled  by  the  gen- 
erous use  of  morphin. 

3.  Acute  retention  of  urine,  partial  or  complete,  is  often  present. 
If  an  acute  retention  occurs  during  an  acute  gonorrhea,  it  is  nearly 
always  caused  by  a  prostatic  abscess.     The  retention  may  be  the  only 
symptom. 

4.  The  general  symptoms  may  be  those  of  any  acute  infection,  chill, 
vomiting,  fever,  etc. 

Physical  Signs. — The  prostate  (by  rectal  examination)  is  enlarged  as 
a  whole  or  in  part.  It  may  be  very  tense  and  hard,  or  if  the  abscess 
is  formed,  soft  and  fluctuating.  The  gentlest  palpation  may  cause  one 
of  the  abscesses  to  rupture. 

Course. — If  only  miliary  abscesses  are  present,  these  may  resolve 
without  any  appreciable  increase  in  the  discharge  of  pus.  An  abscess 
may  form  which  may  rupture  into  the  urethra  or  rectum;  or  it  may 
point  in  the  ischiorectal  fossa  or  in  the  corpora  cavernosa  or  in  the 
scrotum.  A  prostatic  abscess  rarely  ruptures  in  the  portion  of  the 
prostate  anterior  to  the  urethra.  Periprostatic  abscesses  often  com- 
plicate matters. 

Thrombosis  and  metastatic  abscess  are  fairly  rare. 

Acute  seminal  vesiculitis  is  always  associated  with  posterior  ureth- 
ritis,  the  symptoms  of  which  often  mask  the  symptoms  of  the  former. 
It  is  hard  to  tell,  however,  how  often  a  posterior  urethritis  is  com- 
plicated by  a  seminal  vesiculitis.  The  finger  passed  into  the  rectum 
reveals  an  enlarged,  tense,  seminal  vesicle  above  the  prostate. 

The  inflammation  may  resolve  and  the  seminal  vesicle  may  discharge 
its  pus  into  the  urethra,  or  more  rarely  it  may  rupture  into  the  ischio- 
rectal fossa,  rectum,  or  peritoneal  cavity,  or  the  condition  may  become 
chronic. 

Symptoms  of  Chronic  Anterior  Urethral  Gonorrhea. — It  is  hard  to  say 
exactly  when  a  gonorrhea  ceases  to  be  acute  and  becomes  chronic. 
When  the  acute  symptoms,  the  burning  on  urination,  and  the  frequency 
of  urination  cease  and  examination  shows  that  gonococci  are  still 
present,  then  the  case  goes  into  the  chronic  list.  Many  an  acute  case 
never  becomes  chronic.  Every  chronic  case  is  potentially  acute,  and 
as  long  as  the  gonococci  are  present  in  the  urethra  or  its  glands  acute 
flare-ups  may  occur. 

Cause. — The  reason  that  gonorrhea  becomes  chronic  involves  the 
many  questions  of  a  patient's  resistance,  previous  damage  to  the 
urethra,  malformations  of  the  urethra,  improper  treatment,  virulence 
of  the  gonococci,  etc.  Because  of  these  many  factors  it  is  impossible 
to  make  more  than  a  poor  guess  as  to  what  cases  will  become  chronic. 
If  accurate  bacteriological  tests  are  made,  it  will  be  found  that  in  most 
chronic  cases  the  gonococcus  is  associated  with  other  organisms.  What 
effect  these  have  in  causing  the  gonorrhea  to  persist  is  unknown. 
Apparently  the  other  organisms  are  fairly  innocuous,  and  it  is  the 
gonococcus  that  does  damage. 

While  the  symptoms  of  a  chronic  anterior  and  posterior  urethral 


308  IXFECTIOXS  OF    URETHRA   AXD   I1  ROUT  ATE 

gonorrhea  are  much  the  same;  while  the  site  of  the  inflammation  is 
only  revealed  by  the  physical  examination;  and  while  the  one  often 
exists  in  conjunction  with  the  other,  it  is  nevertheless  a  fact  that  if  we 
determine  which  focus  is  the  principal  one  the  eradication  of  this  focus 
will  often  cure  the  gonorrhea  in  the  secondary  focus. 

For  example,  if  we  find  that  chronic  anterior  and  posterior  gonorrhea 
exists  and  that  the  prostate  is  full  of  pus,  proper  treatment  of  the  pros- 
tate will  cure  the  gonorrhea.  If  there  are  cysts  or  granulations  in  the 
anterior  urethra,  then  eradicating  these  will  generally  cure  the  gonor- 
rhea in  both  anterior  and  posterior  urethra. 

Urethral  Discharge. — It  is  this  discharge  which  generally  brings  the 
patient  to  the  physician.  The  discharge  may  be  pussy,  mucoid,  or 
watery;  yellow,  white,  or  colorless.  The  discharge  shows  under  the 
microscope  pus  cells  and  epithelia,  either  predominating;  gonococci  are 
found  either  intracellularly  or  extracellularly. 

Pai?i,  if  present,  is  generally  an  itching  or  mere  tickling  referred  to 
the  end  of  the  penis  or  urethroscrotal  angle  or  indefinitely  along  the 
urethra. 

Physical  Examination. —  Urine. — There  are  shreds*  or  pus  only  in 
the  first  passed  glass  of  Urine. 

Palpation. — Enlarged  glands  may  be  felt  along  the  urethra.  If  a 
sound  is  introduced  into  the  urethra,  the  glands  can  be  more  easily  felt. 

Instrumentation. — A  silk  or  metal  bulbous  bougie  as  large  as  the 
meatus  will  admit  is  introduced  and  roughenings,  granular  places  that 
easily  bleed  or  distinct  strictures  are  sought. 

The  meatus  should  be  at  least  24  F.  to  make  such  an  examination 
efficient.  If  it  is  not  as  large  as  this,  a  meatotomy  to  26  or  28  F. 
should  be  first  performed. 

Urethroscopy. — The  more  often  urethroscopy  is  done  in  intractable 
cases,  the  more  often  is  the  cause  of  the  persistence  of  a  stubborn 
gonorrhea  found.  An  open  tube  urethroscope  with  or  without  water 
dilatation  or  a  urethroscope  with  a  lens  system  with  water  dilatation 
maybe  used.  For  purposes  of  diagnosis  I  personally  prefer  the  latter. 

Pathological  changes  caused  by  the  gonococcus  and  seen  with  the 
urethroscope  are  (1)  chronic  diffuse  inflammation;  (2)  inflammation 
around  ducts  of  urethral  glands;  cysts  of  the  urethral  glands;  (3) 
granulations  or  polypi;  (4)  phosphatic  incrustations  on  an  inflamed  or 
ulcerated  base. 

Indications  for  Urethroscojjy. — It  should  be  done  in  all  cases  of 
persistent  gonorrhea.  The  one  absolute  contra-indication  is  acute 
inflammation  of  the  urethra. 

*  Keyes  emphasizes  the  fact  that:  (1)  "  Shreds  are  no  index  of  gonorrhea.  They  are 
currently  found  in  the  urine  passed  by  men  who  have  never  had  gonorrhea.  (2)  The 
shape  and  size  of  shreds  does  not  indicate  what  part  of  the  urethra  they  come  from. 
(3)  Shreds  mean  chronic,  localized  inflammation  of  the  urethra.  (4)  Shreds  heavy  with 
pua  eink  rapidly  in  the  urine.  They  indicate  active  inflammation  or  ulcer  or  stricture. 
(5)  Lighter  shreds  often  testify  to  an  inflammation  so  mild  that  it  presents  no  danger 
and  is  entirely  uninfluenced  by  treatment.  Shreds  call  for  treatment  by  dilatation 
(unless  this  irritates)." 


THE  GONOCOCCUS  309 

Diagnosis. — I  do  not  believe  that  from  the  symptoms  or  physical 
signs  a  gonorrheal  urethritis  can  be  differentiated  from  a  non-gonorrheal 
urethritis.  Either  may  be  acute  or  chronic;  either  may  be  of  short  or 
long  duration;  the  final  test  is  to  find  the  gonococcus  either  in  a  smear 
or  by  a  culture. 

Such  conditions  as  tuberculosis  of  the  urethra,  leukoplakia,  and  other 
rare  conditions  may  give  all  the  symptoms  of  a  non-gonorrheal  ureth- 
ritis. They  will  be  revealed  by  the  urethroscope. 

Other  conditions  from  which  an  anterior  urethritis  must  be  diagnosed 
are  infections  above  the  triangular  ligament.  These  can  be  accurately 
diagnosed  by  the  five-glass  test,  by  the  urethroscope,  and  by  the 
cystoscope. 

Evidence  of  Cure. — Clinical. — If  the  urine  from  the  urethra  is  pus- 
free,  that  urethra  is  gonococci-free.  This  means  pus-free  as  regards 
any  shreds  in  the  urine  and  pus-free  after  massage  of  the  anterior 
urethral  glands,  and  dilatation  of  the  anterior  urethra.  If  the  patient 
has  pus  in  the  anterior  urethra  in  which  gonococci  cannot  be  found,  a 
silver  nitrate  solution  (1  or  2  per  cent.)  or  a  sound  may  be  used  to  stir 
up  any  latent  gonorrhea.  I  now  never  use  this  method.  It  may  stir 
up  a  somewhat  intractable  urethritis.  Cultural  methods  are  more 
accurate. 

Complement-fixation  Test  (p.  296). — A  positive  reaction  in  anterior 
urethritis,  no  matter  how  acute  or  how  chronic,  is  never  obtained. 
A  similar  condition  of  affairs  is  found  in  acute  vulvovaginitis  in  the 
adult  female. 

Culture. — If  the  anterior  urethritis  is  not  pus-free,  a  culture  has  to  be 
relied  upon  (see  p.  295). 

Complications  of  Chronic  Anterior  Gonorrhea. — The  one  important 
complication  is  stricture  of  the  urethra  (p.  384,  Chap.  XI). 

Symptoms  of  Chronic  Posterior  Urethral  Gonorrhea. — Chronic  posterior 
urethritis  is  chronic  prostatitis  either  alone  or  combined  with  a  chronic 
inflammation  of  the  seminal  vesicles  or  chronic  inflammation  of  the 
verumontanum . 

Etiology. — It  is  the  gonococcus  we  always  seek,  and  here  in  the 
prostate  it  loves  to  stick.  Two  factors  in  the  etiology  are  important : 

1 .  In  prostatitis  originally  caused  by  the  gonococcus,  if  the  prostatitis 
persists  and  if  no  new  gonococcal  infection  occurs,  the  gonococcus  is 
gradually  replaced  by  other  organisms,  so  that  at  the  end  of  the  fourth 
year  (this  is  the  long  limit)  all  cases  are  gonococci-free.     (These  are 
statistics  from  the  Lehrbuch  der  Urologie.)     Keyes,  less  conservative 
and  probably  more  accurate,  says :  "  I  believe  that  the  gonococcus  does 
not  persist  in  the  male  urethra  for  more  than  three  years;  while  in  at 
least  90  per  cent,  of  cases  it  disappears,  with  or  without  treatment, 
within  the  year." 

2.  Not  all  cases  of  prostatitis  are  gonorrheal  in  origin.     In  358  cases, 
Young,  Geraghty,  and  Stevens  found  that  a  previous  history  of  gonor- 
rhea was  present  in  but  73.2  per  cent.     The  remaining  cases  gave 
histories  of  masturbation  (which  is  a  good  general  history  of  all  genito- 


310  INFECTIONS  OF   URETHRA  AND  PROSTATE 

urinary  cases)  or  prolonged  sexual  excitement,  traumatism,  instrumen- 
tation, infectious  diseases.     In  14  per  cent,  no  etiology  was  obtained. 

Urethral  Discharge. — A  chronic  urethral  discharge  is  often  the  sole 
symptom  of  a  prostatitis.  Such  a  discharge  may  be  caused  by  the 
prostatic  secretion  running  into  the  anterior  urethra  or  by  an  accom- 
panying anterior  urethritis. 

Disturbances  of  Urination. — The  day  and  night  frequency  of  the 
acute  prostatitis  may  persist  and  be  a  feature  of  the  chronic  form. 
There  may  be  urgency,  pain  on  urination,  or  terminal  pain — typical 
irritable  prostatitis.  There  may  be  obstruction  to  urination  caused  by 
contracture  of  the  bladder  neck;  the  obstruction  causing  partial  or 
complete  retention.  Our  attention  then  turns  from  a  less  important 
prostatitis  to  the  graver  contracture. 

Pain. — As  abnormalities  of  the  verumontanum  are  being  more 
studied,  we  are  coming  to  believe  that  many  of  the  pains  formerly 
attributed  to  a  diseased  prostate  are  due  to  some  pathological  condition 
of  the  verumontanum.  As  the  two  often  occur  together  it  is  hard  to 
differentiate  the  symptoms  caused  by  either.  A  diseased  prostate 
perhaps  plus  a  diseased  verumontanum  may  give  a  feeling  of  fulness 
or  pain  or  burning  in  the  prostate  itself.  This  is  often  relieved  after 
emptying  a  prostate  of  its  contents  by  massage.  Pain  in  the  urethra 
either  referred  to  the  penoscrotal  angle  or  to  the  end  of  the  penis  is 
probably  more  often  due  to  disease  of  the  verumontanum.  Perineal 
pain  is  often  present  or  the  pain  may  be  referred  to  the  testicles  or 
cord. 

Because  of  the  varied  sites  of  the  prostatic  pain,  confusion  in  the 
diagnosis  often  arises,  and  an  appendicitis,  ureteral  or  bladder  stone  and 
many  other  conditions  have  been  confused  with  a  simple  prostatitis. 

Disturbances  in  the  Sexual  Function. — These  are  probably  more  due 
to  disease  of  the  verumontanum  than  to  prostatitis.  They  comprise 
all  the  symptoms  usually  classed  under  sexual  neurosis,  viz.,  premature 
or  delayed  ejaculation,  too  frequent  seminal  emissions,  poor  or  painful 
erections  and  the  like. 

Exacerbations. — Those  patients  who  have  frequent  flare-ups  (not 
reinfections)  due  to  sexual,  alcoholic,  or  instrumental  excesses  generally 
have  a  focus  in  the  prostate.  These  attacks  are  commonly  and  fairly 
accurately  designated  by  the  patients  as  strains. 

Physical  Examination. — Pus  in  the  Urine. — The  modified  method  of 
Kollman  may  be  used,  but  the  more  practical  office  method  is  to  have  the 
patient  empty  his  bladder,  then  massage  the  prostate  and  examine  the 
drop  that  generally  appears  at  the  meatus.  If  it  contains  pus  cells, 
then  the  prostate  is  the  offending  member.  Sometimes  a  drop  does  not 
appear  at  the  meatus;  instead  the  pus  is  forced  back  into  the  bladder. 
If  so,  have  the  patient  pass  the  few  cubic  centimeters  of  urine  that  have 
collected  in  his  bladder.  This  is  examined  under  the  microscope. 

Palpation. — An  enlarged  boggy  prostate  which  pits  on  pressure,  or 
a  lumpy  and  hard  prostate,  may  be  felt;  or  one  may  feel  an  entirely 
normal  prostate  from  which  a  drop  of  pus  may  be  expressed.  If  a 


THE  GONOCOCCUS  311 

stained  specimen  is  carefully  examined,  gonococci  will  usually  be  found, 
but  this  examination  is  not  to  be  depended  upon.  A  complement- 
fixation  test  or  a  culture  is  the  only  safe  test. 

Warning. — An  acute  epididymitis  is  not  infrequently  caused  by  the 
too  frequent  or  too  harsh  massage  of  the  diseased  prostate.  Gentle- 
ness first ! 

Instrumental. — A  bulbous  bougie  as  large  as  will  pass  the  meatus 
(24  F.  at  least)  is  introduced  into  the  posterior  urethra  as  far  as  the 
vesical  sphincter.  This  is  withdrawn  and  any  roughenings,  narrowings, 
or  undue  bleeding  on  the  withdrawal  of  the  bougie  are  noted. 

Contracture  of  the  bladder  neck  cannot  be  diagnosed  in  this  way 
(see  Vol.  II). 

Urethroscopy. — By  using  the  modern  irrigating  urethroscopes  we 
more  often  find  a  reason  for  the  deadly  persistence  of  the  gonococcus 
in  the  posterior  urethra.  Urethroscopy  tells  us  nothing  of  what  is 
happening  in  the  interior  of  the  prostate,  but  is  used  to  reveal  patho- 
logical processes  of  the  posterior  urethra,  and  particularly  of  the 
verumontanum . 

Pathological  Lesions  Seen  by  Urethroscopy:  (1)  Enlarged  and  boggy 
verumontanum;  (2)  cysts  of  the  verumontanum  or  posterior  urethra; 
(3)  granulations  or  papilloma  of  the  verumontanum  or  posterior  ure- 
thra; (4)  inflammation  around  the  ejaculatory  ducts;  (5)  diverticula, 
natural  or  acquired  (postoperative),  of  the  posterior  urethra;  (6)  in- 
crustations on  an  inflamed  or  ulcerated  base. 

Indications  for  Urethroscopy. — These  vary  with  the  type  of  the  in- 
strument used.  I  believe  more  and  more  that  Urethroscopy  is  worthless 
with  the  non-irrigating  instruments.  It  should  be  performed  in  all 
stubborn  cases  of  chronic  prostatitis.  This  indication  has  naturally  a 
wide  latitude  and  what  would  be  an  indication  for  one  urologist  would 
not  be  such  for  another.  Urethroscopy  should  always  be  the  last  of  all 
examinations. 

Contra-indications. — All  acute  inflammations  of  the  urethra. 
Urethroscopy  to  Confirm  Cure. — Much  has  been  written  particularly 
by  the  German  urologists  about  never  discharging  a  case  as  cured  with- 
out complete  Urethroscopy.     I  believe,  however,  that  Urethroscopy 
does  not  tell  when  a  patient  is  cured  but  why  a  patient  is  not  cured. 

Course  of  Chronic  Prostatitis. — Cases  may  be  very  stubborn;  they  may 
relapse  so  often  that  a  cure  seems  impossible.  Opposed  to  this  is  the 
extreme  mildness  of  others  which  immediately  respond  to  appropriate 
treatment.  In  no  case  can  a  physician,  with  any  degree  of  accuracy, 
predict  the  course ;  all  that  he  can  do  is  to  intelligently  follow  the  course. 

Complement-fixation  Test. — This  is  positive  when  a  posterior  gonor- 
rhea has  been  present  for  a  month  or  more.  Occasionally  if  the  posterior 
urethritis  is  very  acute,  it  appears  earlier  (see  p.  297  et  seq.}. 

Diagnosis. — The  differential  diagnosis  is  between  gonorrheal  pros- 
tatitis and  (1)  non-gonorrheal  prostatitis;  (2)  seminal  vesiculitis; 
(3)  inflammation  of  the  verumontanum ;  (4)  papillomata,  granulations, 
ulcerations,  and  rarer  conditions,  as  tuberculosis,  leukoplakia  of  the 


312  INFECTIONS  OF   rRKTIIHA    AXD  PROSTATE 

posterior  urethra;  (5)  inflammation  of  the  urinary  tract  above  the 
prostate. 

1.  Non-gonorrheal  Prostatitis, — A  prostatitis  troubles  a  patient  not 
especially  because  of  its  symptoms  but  because  he  believes  it  an  uncured 
gonorrhea.     Most  cases  of  prostatitis  are  in  fact  gonorrheal  in  origin, 
therefore  a  smear  of  the  prostatic  secretion,  or  a  culture,  or  a  comple- 
ment-fixation test  for  gonorrhea  is  made  to  determine  if  gonococci  are 
still  causing  the  trouble.     AYhether  the  prostatitis  is  gonorrheal  or  not, 
the  patient  is  now  put  on  an  appropriate  course  of  treatment.     If  treat- 
ment of  two  or  three  weeks  fails  to  produce  any  effect,  then  urethros- 
copy  or  cystoscopy  should  be  performed. 

2.  Seminal  vesiculitis  is  always  accompanied  by  prostatitis.     Which 
is  the  principal  infection  is  determined  partially  by  palpation  and  par- 
tially by  first  massaging  the  prostate  and  examining  the  secretion  and 
then  massaging  the  seminal  vesicles  and  examining  their  secretion. 

3.  Inflammation  of  the  I  rerumontanum. — This,  like  the  above,  is  prob- 
ably always  accompanied  by  prostatitis,  and  it  is  probable  that  the 
treatment  used  to  cure  the  prostatitis  in  most  cases  cures  the  inflamma- 
tion of  the  verumontanum.     The  differentiation  is  made  by  examining 
the  prostatic  secretion  microscopically  and  the  verumontanum  through 
the  urethroscope. 

4.  Cysts,  papillomata,  granulations,  ulcerations,  and  rarer  condi- 
tions, as  tuberculosis  and  leukoplakia,  can  be  differentiated  with  the 
urethroscope  alone.     The  first  four  are  frequently  caused  by  gonor- 
rhea; they  are  particularly  prone  to  be  about  or  on  the  verumon- 
tanum; and  when  present  keep  up  inflammation. 

5.  Inflammation  of  the  urinary  tract  above  the  prostate.     In  these 
cases  a  complete  cystoscopy  is  often  necessary  to  make  the  diagnosis. 

Evidence  of  Cure. — Clinical. — Practically  all  urologists  believe  that  a 
pus-free  urine  means  a  urethra  free  from  gonococci. 

But  most  urologists  insist  that  a  patient  remain  a  certain  length  of 
time  pus-free  before  declaring  a  man  cured.  Keyes  puts  this  at  three 
months.  By  pus-free  is  meant  neither  free  pus  nor  pus  shreds  in  the 
morning  urine  or  in  the  urine  passed  after  massage  of  the  prostate  and 
seminal  vesicles.  If  three  months  have  not  elapsed  or  if  a  patient  has 
free-pus  or  pus  shreds  in  his  urine  or  pus  in  the  secretion  expressed  from 
the  prostate  and  seminal  vesicles,  then  a  negative  culture  or  negative 
complement-fixation  test  is  necessary  to  declare  the  patient  gonococcus- 
free.  Most  cases  of  this  class,  if  they  still  harbor  gonococci,  indicate  it 
by  having  an  acute  exacerbation  of  the  urethritis  or  by  an  attack  of  one 
of  the  complications  of  gonorrhea;  seminal  vesiculitis  or  epididymitis. 
These  exacerbations  are  apt  to  follow  sexual  indiscretions,  instrumenta- 
tion, too  violent  exercise,  or  the  immoderate  use  of  alcohol. 

Complications  of  Chronic  Posterior  Gonorrhea. — In  acute  flare-ups 
chronic  posterior  gonorrhea  may  present  any  or  all  of  the  complications 
of  acute  posterior  gonorrhea.  Practically  the  only  other  complication, 
if  we  except  chronic  seminal  vesiculitis  (p.  313),  is  contracture  of  the 
bladder  neck  (see  Vol.  II). 


TREATMENT  OF  GONORRHEA  313 

SYMPTOMS    OF   SEMINAL   VESICULITIS. 

Caulk1  gives  a  brief  and  pithy  summary  of  the  symptoms  which  may 
be  caused  by  seminal  vesiculitis: 

"  Various  chronic  discharges,  many  chronic  bladder  distresses;  the 
numerous  referred  pains  in  the  back,  sacral  region,  hips,  legs,  perineum, 
groins,  testicles,  and  penis;  recurrent  epididymitis  and  sexual  derange- 
ments; a  vast  array  of  joint  processes  of  an  infectious  nature,  such  as 
articular  rheumatism,  rheumatoid  arthritis,  arthritis  deformans,  and 
hypertrophic  arthritis,  numerous  renal  and  cardiac  complications, 
digestive  upsets,  and  an  array  of  nervous  and  mental  manifestations 
which  are  almost  inconceivable." 

The  finger  passed  into  the  rectum  reveals  an  enlarged  more  or  less 
tense  seminal  vesicle  to  the  outer  and  upper  angle  of  the  prostate. 
The  whole  vesicle  can  by  no  means  be  felt.  If  a  radiograph  is  desired 
the  vas  is  exposed  by  a  small  incision  in  the  scrotum  and  10  per  cent, 
collargol  injected  by  means  of  a  small  needle  into  the  cavity  of  the  vas. 
This  may  be  easily  done  after  a  little  practice  without  incising  the  vas. 
Immediately  following  the  collargol  injection  a  radiograph  is  taken. 

TREATMENT    OF   GONORRHEA. 

Prophylaxis  Against  Gonorrhea. — The  real  prophylaxis  against  gonor- 
rhea, as  suggested  in  another  place,  begins  with  the  education  of 
youth  against  promiscuous  sexual  intercourse. 

The  lesser  and  more  uncertain  prophylaxis  is  applicable  to  those 
who  have  indulged  in  promiscuous  intercourse:  (1)  Prolonged  sexual 
intercourse  favors  the  acquisition  of  gonorrhea,  as  does,  also  drunken- 
ness on  the  part  of  the  male;  the  latter  because  it  increases  congestion 
of  the  sexual  organs  and  also  tends  to  prolong  intercourse.  (2)  Gono- 
cocci  live  in  the  alkaline  semen,  and  the  alkaline  secretion  of  the 
urethral  glands  tends  to  keep  them  alive.  They  readily  die  in  an  acid 
medium ;  therefore  the  desirability  of  the  subject  urinating  immediately 
after  coitus  (thus  mechanically  cleansing  the  urethra  and  saturating 
it  with  an  acid  urine).  (3)  Soap  and  water  vigorously  applied  to 
the  penile  head  probably  cleanse  better  than  antiseptics.  The  sooner 
they  are  applied  the  more  certainty  of  killing  the  gonococci.  In  addi- 
tion an  antiseptic  solution,  such  as  bichloride  of  mercury,  1  to  2000, 
may  be  used  to  wash  the  head  of  the  penis. 

If  the  patient  follows  all  this  with  urethral  injections  he  may  succeed 
in  evading  the  enemy.  Probably  the  best  injections  are  a  0.5  or  1  per 
cent,  protargol  and  10  to  20  per  cent,  argyrol.  These  are  carried  in 
bottles  and  injected  by  means  of  a  syringe  or  are  put  up  in  small 
collapsible  tubes  (one  tube  sufficing  for  one  application)  and  injected 
therefrom.  The  army  has  used  with  a  good  deal  of  success  calomel 
preparations.  Henry4  recommends  the  following: 

Calomel 50  grams 

Vaselin  liq 80  c.c. 

Lanolin 70  grams 


314  INFECTIONS  OF   URETHRA  AND  PROSTATE 

Sailors  carry  tubes  of  this,  and  part  is  injected  into  the  urethra  and 
part  is  smeared  over  the  head  of  the  penis.  Henry  tells  of  529  sailors 
who  were  exposed  to  infection,  only  4  of  whom  acquired  gonorrhea. 

Hygiene  Cleanliness. — The  instructions  under  this  head  apply  par- 
ticularly to  cases  of  acute  gonorrhea. 

The  end  of  the  penis  is  washed  in  soap  and  water  at  least  once  a  day. 
If  there  is  a  foreskin,  this  is  retracted  and  well  cleansed.  The  patient 
then  thoroughly  washes  his  hands  with  soap  and  water  (individual 
soap  and  individual  towel),  and,  while  a  patient  very  rarely  infects  him- 
self ("in  fifteen  years  of  office  experience  I  cannot  recall  a  single  case 
of  conjunctival  infection  among  the  patients  who  came  to  see  me  with 
urethral  gonorrhea" — Keyes),  it  is  wrell  to  instruct  the  patient  not 
to  rub  his  eyes  with  his  fingers. 

Discharge. — If  the  discharge  is  slight,  almost  any  dressing  \vhich 
prevents  soiling  the  patient's  clothes  is  sufficient.  If  it  is  profuse  a 
strip  of  two-inch  gauze  bandage,  perforated  to  admit  the  glans  penis, 
is  used.  The  gauze  is  slipped  back  of  the  corona  and  the  foreskin  is 
pulled  forward,  holding  the  gauze  in  place.  Lacking  foreskin,  the 
penis  is  held  in  a  gauze  bag. 

The  patient  is  particularly  instructed  not  to  use  a  common  bath 
tub  while  the  acute  discharge  lasts  and  to  keep  the  discharge  away  from 
the  toilet  seat.  This  to  protect  other  members  of  the  family. 

Rest. — Much  sleep;  rest  as  much  as  possible;  reduced  physical  exer- 
cise; riding  instead  of  walking;  no  dancing;  all  of  these  are  important. 
Under  this  head  is  sexual  rest;  erections  are  harmful.  A  suspensory 
bandage  or  jock-strap  is  advised  in  the  acute  stage. 

Food. — Alcohol  is  absolutely  contra-indicated.  Spices  are  forbidden, 
although  the  writer  believes  that  they  rarely  do  harm.  Coffee  and 
tea  should  be  used  in  moderation.  Water  should  be  much  increased 
in  an  anterior  gonorrhea;  as  the  oftener  the  urethra  is  washed  out  by 
the  diluted  urine  the  better.  In  posterior  gonorrhea,  however,  too 
much  water  may  dojiarm.  The  frequency  of  urination  that  it  causes 
may  irritate  the  urethra. 

Bowels. — At  least  one  movement  a  day  is  necessary. 

Internal  Medication. — Balsamics: 

Compound  Salol. — Salol,  3|  grains;  copaiba,  10  minims;  oleoresin 
cubeb.,  5  minims;  pepsin  (1  to  3000),  1  grain. 

Salol  and  Santal. — Salol,  4  grains;  oleoresin  santoli,  5  minims; 
oleoresin  cubeb.,  5  minims;  olive  oil,  5  minims;  pepsin  (1  to  3000),  1 
grain. 

Sandalwood  oil,  10  minims. 

Wintergreen  oil,  10  minims. 

Stearosan,  10  minims. 

All  of  these  are  given  in  capsule :  One  capsule  three  times  a  day  after 
meals,  with  a  full  glass  of  water.  There  are  many  other  combinations 
and  many  other  more  or  less  non-irritating  preparations  of  sandal- 
wood  oil.  These  suffice,  however. 

I  prefer  compound  salol  or  sandal  wood.     If  these  upset  the  stomach 


TREATMENT  OF  GONORRHEA  315 

I  try  stearosan  or  reduce  the  number  of  capsules  or  stop  them  entirely. 
If  the  sandalwood  gives  pain  in  the  kidney  regions,  cut  down  or 
entirely  withdraw  the  capsules,  resuming  the  treatment  carefully  in  a 
day  or  so.  Any  of  these  given  over  a  long  period  loses  its  efficiency; 
therefore  the  need  of  changing  them. 

The  rule  for  their  administration  is  to  give  them  as  soon  as  the  patient 
presents  himself  with  an  acute  gonorrhea  and  stop  (unless  there  is 
indigestion  or  kidney  congestion)  when  the  urine  becomes  clear  (not 
meaning  free  from  shreds). 

Anodynes. — One  of  the  standard  anodynes  which  is  given  to  decrease 
the  pain  on  urination  is  the  following  prescription : 

R — Liq.  potassae 8-  25  gr. 

Tr.  hyoscyami 15-  35  gr. 

Aq.  cinnamomi q.  s.  ad.  100  gr. 

M.     Sig. — Teaspoonful  in  water  every  3  hours. 

This,  as  the  prescription  shows,  combines  an  alkali  with  an  anodyne. 
Alkalies  alone  may  be  given  in  the  form  of  an  alkaline  water,  or  simple 
bicarbonate  of  soda.  If  there  is  much  pain,  as  for  instance  occurs  in 
prostatic  abscess,  morphin  or  one  of  its  derivatives  may  be  indicated. 
For  prostatic  pain  and  tenesmus,  suppositories  of  morphin  are  often 
used.  Morphin  thus  given  probably  does  not  act  locally,  but  only 
quiets  the  pain  after  absorption.  The  morphin  is  therefore  better 
given  by  mouth  or  hypodermically.  Hot  and  cold  water  are  excellent 
anodynes.  Hot  hip  baths  may  be  taken,  with  the  water  as  hot  as  can 
be  borne;  or  the  patient  may  urinate  while  the  penis  is  immersed  in  a 
vessel  of  hot  water.  Cold  water  is  particularly  useful  in  combating 
painful  erections.  Bromides  are  also  used  for  this  purpose:  sodium 
bromide,  grains  30,  before  retiring. 

In  the  following  pages  certain  methods  of  treatment  are  discussed. 
For  the  application  of  these  methods  see  Case  Treatment  of  Gonor- 
rhea. 


FIG.  164. — Urethral  syringe. 

Anterior  Urethral  Injections. — The  patient  uses  an  all-glass,  two-dram, 
blunt-nosed,  urethral  syringe  (Fig.  164).  All-glass  because  it  may  be 
cleaned  easily;  quarter-ounce  to  prevent  too  large  an  injection;  blunt- 
nosed  to  prevent  hurting  the  urethra.  He  fills  the  syringe  half-full 
of  the  solution  which  is  in  a  bottle  with  a  wide  enough  neck  to  admit 
the  syringe.  He  urinates.  The  syringe  is  held  in  his  right  hand.  The 
end  of  the  penis  is  grasped  behind  the  corona  between  the  middle  and 
ring  fingers  of  the  left  hand.  The  urethral  meatus  is  held  open  with 
the  thumb  and  index  finger  of  the  same  hand.  The  blunt  nose  of  the 
syringe  is  firmly  placed  in  the  meatus  and  the  injection  slowly  intro- 
duced. The  syringe  is  removed  and  the  meatus  closed  by  the  same 


316  ixFEcnoxs  OF  URETHRA  AXD  PROSTATE 

thumb  and  index  finger  and  the  fluid  thus  retained  in  the  urethra. 
The  perineal  urethra  is  not  compressed  to  prevent  the  fluid  from  enter- 
ing the  posterior  urethra.  This  injures  the  urethra  and  excites, 
rather  than  hinders,  the  extension  of  the  gonorrhea  into  the  posterior 
urethra;  forcing  a  gonococcus-laden  injection  into  the  posterior  urethra 
and  so  causing  a  posterior  urethritis  is  largely  a  myth.  Injuring 
a  urethra  by  a  too  large  injection  or  by  an  injection  violently  given  is 
another  thing.  The  fluid  is  held  in  the  urethra  varying  lengths  of  time, 
according  to  the  injection  used  (silver  salts  for  five  minutes,  or  until 
they  burn;  astringent  injections  for  one-half  minute).  The  injection 
is  used  from  one  to  three  times  a  day.  The  syringe  is  washed  in  hot 
water  at  least  once  a  day. 

Posterior  Urethral  Irrigation. — The  most  satisfactory  method  of 
irrigating  the  posterior  urethra  is  as  follows: 

A  soft-rubber  16  F.  catheter  is  introduced  into  the  bladder.  This 
catheter  serves  two  purposes:  (1)  the  irrigating  solution  is  introduced 
through  it  into  the  bladder;  (2)  it  acts  as  a  sound  and  squeezes  pus  out 
of  the  ducts  of  the  urethral  glands,  smooths  down  granulations,  etc. 
The  catheter  is  now  withdrawn  and  the  patient  empties  his  bladder; 
so  irrigating  the  urethra.  Some  recommend  the  insertion  of  the 
catheter  as  far  as  the  posterior  urethra,  but  not  into  the  bladder,  and 
then  injecting  the  irrigating  fluid.  This  seems  to  be  a  little  more 
likely  to  harm  the  urethra  than  if  the  former  method  be  used. 

Another  way  of  irrigating  the  posterior  urethra  is  to  force  the  fluid 
into  the  bladder  without  the  aid  of  a  catheter.  The  patient  is  told 
to  relax  the  sphincters  of  his  posterior  urethra  (he  soon  gets  the  knack) 
and  then  the  fluid  is  forced  into  the  bladder  either  by  means  of  a 
large  hand  syringe  whose  blunt  nozzle  is  inserted  into  the  urethral 
meatus  or  by  gravity.  The  gravity  apparatus,  about  three  feet  above 
the  level  of  the  patient,  is  so  arranged  as  to  be  elevated  or  lowered  at 
will.  In  my  experience  this  method  is  not  so  good  as  the  catheter 
method. 

The  most  popular  solutions  used  are:  Protargol,  1  to  400  to  1  to  200; 
silver  nitrate,  1  to  10,000  to  1  to  1500;  potassium  permanganate,  1  to 
5000  to  1  to  2000;  zinc  sulphate,  1  to  500  to  1  to  200;  zinc  permangan- 
ate, 1  to  4000  to  1  to  2000;  silver  permanganate,  1  to  4000  to  1  to 
2000. 

Prostatic  Massage. — A  finger  cot  is  placed  on  the  index  finger  of  the 
right  hand;  the  base  of  the  finger  cot  is  surrounded  by  cotton  to 
protect  the  hand  from  being  soiled.  The  protected  finger  is  dipped  in 
vaseline;  the  patient  leans  over  the  edge  of  a  table  or  chair;  the  left 
hand  is  placed  on  the  patient's  left  shoulder  for  leverage  and  the  right 
index  finger  is  inserted  into  the  rectum  as  far  as  it  will  go.  The  upper 
margin  of  the  prostate  is  felt  and  the  massaging  finger  presses  on  the 
prostate  as  the  finger  is  withdrawn;  the  right  lobe  first  and  then  the 
left  lobe  is  massaged  downward  in  this  way  (Fig.  165).  If  in  addition 
it  is  wished  to  massage  the  seminal  vesicles,  these  are  felt  above  the  upper 
and  outer  angles  of  the  prostate  and  pressed  upon  in  that  position.  In 


TREATMENT  OF  GONORRHEA  317 

almost  every  case  it  is  desirable  to  massage  the  prostate  at  the  same 
time  the  seminal  vesicles  are  massaged,  because  if  there  is  infection 
of  the  latter  there  is  always  infection  of  the  former.  According  to 
indications  the  massage  varies  from  a  gentle  pressure  on  the  prostate, 
lasting  a  second,  to  vigorous  stripping  of  the  prostate  for  one  or  two 
minutes.  No  matter  how  chronic  the  case,  massage  should  always  be 
very  gentle  at  first. 


FIG.   165. — Massage  of  prostate.     Arrows  indicate  direction  and  extent  of  prostatic 
massage.    Prostate  below,  seminal  vesicles  and  bladder  above. 

Exploration  with  Bulbous  Bougie. — Some  prefer  a  urethroscope, 
some  a  sound,  and  some  a  bulbous  bougie  in  examining  the  urethra 
for  patches  of  inflammation,  granulations,  etc.  All  instrumental 
examinations  are,  of  course,  reserved  for  cases  of  chronic  urethritis. 
A  bulbous  bougie,  metal  or  gum-elastic,  as  large  as  can  be  admitted 
into  the  urethral  meatus  is  first  used  (Fig.  166).  If  the  meatus  will 
not  admit  at  least  a  24  F.  bougie  the  meatus  is  cut  (to  28  F.)  and  then 
the  exploration  is  undertaken  after  the  meatotomy  wound  has 
healed.  The  bulbous  bougie  is  passed  as  far  as  the  bladder 


FIG.   166. — Olivary  bougie. 

neck  and  then  gently  withdrawn,  and  any  strictures,  roughenings, 
or  granulations  (which  easily  bleed)  are  noted.  Sometimes  because 
of  strictures  a  number  of  different  sizes  of  bulbous  bougies  are  used. 

tyttatation  by  Sounds  and  Kollman  Dilator. — Either  of  these  is 
indicated  when  the  exploration  of  the  urethra  shows  granulations, 
indurations,  or  slight  strictures,  or  when  the  urine  contains  shreds  which 
cannot  be  eliminated  by  irrigations,  instillations,  or  prostatic  massage. 


318 


INFECTIONS  OF   URETHRA  AND  PROSTATE 


"When  dilating  by  sounds  we  begin  with  the  size  of  the  bulbous 
bougie  (the  writer  but  rarely  uses  the  bougie,  preferring  sounds, 
silk,  or  metal)  used  and  increase  it  one  or  two  numbers  twice  a  week. 
If  the  increase  in  size  causes  much  bleeding  and  pain  we  go  very 
slowly  and  perhaps  reduce  the  size  of  the  sound.  Sounds  best  adapted 
are  those  with  the  Benique  curve.  The  size  of  the  sound  used  is  limited 
by  the  size  of  the  meatus.  Therefore,  when  a 
small  meatus  is  present  or  when  more  dilatation 
than  sounds  will  produce  is  wished  we  use  a 
Kollman  dilator  (Fig.  167).  The  dilators  best 
adapted  are  those  with  the  Benique  curve. 

Kollman  dilatation  takes  place  twice  a  week, 
and  the  first  dilatation  is  such  as  to  cause  the 
patient  slight  pain  and  slight  bleeding.  There- 
after the  dilatation  progresses  much  more 
rapidly  than  with  sounds. 

When  shreds  come  from  the  posterior  urethra, 
dilatation  is  often  alternated  with  prostatic 
massage. 

Contraindication  to  D  ila  ta  tion.  —When  the 
urine  is  cloudy  with  pus,  dilatation  should 
rarely,  if  ever,  be  made.  Dilatatioji  should  not 
be  begun  until  the  urethra  has  become  accus- 
tomed to  less  vigorous  instrumentation,  such 
as  that  by  passage  of  rubber  catheters. 

Urethrol  Instillations. — By  means  of  special 
instruments  a  small  quantity  (1  or  2  c.c.)  of 
a  solution  is  distributed  along  the  urethra. 
The  instrument  used  is  the  Keyes  or  Guyon 
instillator,  which  is  a  2  c.c.  syringe  attached  to 
a  hollow'  sound,  16  F.  size  (Fig.  168).  This  is 
filled  with  the  solution  and  the  instrument  intro- 
duced into  the  urethra  in  the  same  manner  as  a 
sound,  until  the  tip  is  just  beyond  the  cut-off 
muscle  in  the  posterior  urethra;  one  can  gener- 
ally feel  the  instrument  jump  slightly  when 
passing  the  cut-off  muscle.  Half  the  solution 
is  injected  with  the  instrument  in  this  position 
and  the  remainder  injected  as  the  instrument  is 
withdrawn. 

Use.  —  Instillations  are  generally  used  in 
chronic  inflammations  of  the  urethra.  In  these 
cases  after  the  urethra  has  become  accustomed  to  urethra!  wsahes 
larger  in  quantity  and  milder  in  strength  than  the  instillations,  one 
instills  a  0.25  or  0.5  per  cent,  silver  nitrate,  1  to  5  per  cent,  copper 
sulphate,  or  other  solution.  Sometimes  instillation  are  given  in 
cases  of  subacute  urethritis,  using  either  protargol,  5  to  10  per  cent., 
or  argyrol,  10  per  cent,  and  upward, 


FIG.  167.  —  Kollman 
posterior  urethral  dilator, 
Uuyon  curve. 


TREATMENT  OF  GONORRHEA  319 

Case  Treatment  of  Gonorrhea. — CASE  I. — Acute  Anterior  Gonorrhea. — 
The  patient  had  a  slight  urethral  discharge  of  one  day's  duration. 
Incubation  four  days.  His  first  gonorrhea.  Neither  burning  nor 
urinary  frequency.  Discharge  contained  pus  cells  and  many  typical 
intracellular  gonococci  (methylene-blue  stain).  Meatus  slightly  red. 
First  urine  cloudy;  many  shreds.  Second  urine  clear. 

This  being  the  patient's  first  gonorrhea,  his  urethra  is  particu- 
larly vulnerable  to  infection  and  we  may  expect  an  acute  and 
long  attack.  On  the  other  hand,  he  came  on  the  second  day  of  his 
discharge  before  any  acute  symptoms  had  set  in,  and  some  days  before 
the  height  of  the  inflammation.  In  this  stage  the  gonococci  are  mostly 
along  the  surface  of  the  urethra,  having  only  slightly  penetrated  the 
epithelial  layer,  and  are  probably  not  yet  in  any  of  the  crypts.  There- 
fore they  are  easily  accessible  and  in  a  position  to  be  readily  killed. 


FIG.  168. — Keyes'  deep  urethral  syringe. 

Should  one  of  the  so-called  abortive  treatments  be  used?*  The  answer 
is  in  the  foot-note. 

An  anterior  injection  of  0.5  per  cent,  protargolf  is  given  to  the 
patient,  and  he  is  told  to  use  this  three  times  a  day,  and  given  com- 
pound salol  capsules.  On  the  second  day  the  discharge  is  less,  urine 
is  clear  but  contains  shreds;  continue  treatment.  On  the  sixth  day  the 
discharge  is  slight. 

*  Abortive  Treatments. — These  are  recommended  by  many  urologists  and  are  applied 
to  cases  like  the  above  in  which  the  discharge  has  persisted  for  but  two  or  three  days. 
In  most  of  the  various  modifications  a  strongly  caustic  solution — 5  to  20  per  cent,  silver 
nitrate  is  a  lavorite — is  injected  into  the  anterior  urethra  with  the  idea  of  killing  all  the 
gonococci  at  one  fell  swoop  (by  some  a  urethroscopic  application  instead  of  injection 
is  recommended).  The  unfortunate  part  played  by  these  treatments  is  that  they  fail 
in  a  goodly  percentage  of  cases  to  kill  all  the  gonococci  and  they  invariably  do  much 
damage  to  the  urethra.  With  the  few  gonococci  left  this  damaged  urethra  is  as  a  virgin 
field ;  and  the  ensuing  gonorrhea  is  much  worse  than  it  would  have  been  had  the  patient 
been  left  entirely  alone. 

//  any  attempt  at  abortive  treatment  is  to  be  made  a  gonococcicide  must  be  chosen  that 
does  not  harm  the  urethra. 

f  Organic  Silver  Salts. — There  are  many  of  these  on  the  market.  Protargol  seems  by 
all  means  the  best.  Argyrol  in  a  5  to  10  per  cent,  solution  often  works  well  in  early 
cases  as  an  anterior  injection.  It  is  less  irritating  than  protargol  and  for  that  reason 
many  prefer  it  in  the  acute  inflammatory  stage,  later  changing  to  protargol  when  the 
argyrol  ceases  to  be  effectual.  Some  skip  the  protargol  and  change  to  one  of  the  astrin- 
gent injections.  All  organic  silver  gaits  should  be  made  up  fresh.  After  being  a  week 
in  solution  they  deteriorate. 


320  IXFECTIOXS  OF    URETHRA   AXD  PROSTATE 

It  is  examined  and  gonococci  are  found  in  one  pus  cell  as  against 
many  gonococci  at  the  time  of  first  examination.  The  patient  is  seen 
only  every  other  day.  Increase  strength  of  anterior  protargol  injection 
to  1  per  cent.,  as  the  0.5  per  cent,  held  in  five  minutes  does  not  irritate. 

By  the  eleventh  day  he  had  no  discharge.  Urine  showed  only  a 
rare  shred;  no  gonococci  found.  On  the  fifteenth  day  internal  medi- 
cation and  injection  discontinued.  Twenty-sixth  day  urine  clear,  no 
shreds. 

Proof  of  Cure. — The  patient  now  has  the  choice  of  (a)  having  a 
bacteriological  examination  made.  If  this  proves  to  be  negative  he  is 
discharged.  This  examination  is  preceded  by  a  gentle  massage  of  the 
anterior  urethral  glands,  which  are  emptied  of  their  contents  by  milk- 
ing the  anterior  urethra  from  behind  forward ;  and  also  of  the  prostate, 
because  one  cannot  be  sure  that  the  urethritis  has  remained  wholly 
anterior.  Or  (6)  he  is  told  to  wait  at  least  two  months,  at  which  time 
if  his  urine  is  pus-free  he  is  discharged. 

Irrigation  of  Janet. — Instead  of  using  a  silver  salt  as  an  internal 
injection  in  this  case  the  Janet  method  of  potassium  permanganate 
injection  might  have  been  used.  This  method  is  used  by  a  great  many 
urologists  and  in  a  great  many  urological  clinics. 

As  far  as  my  experience  has  been  with  the  method  it  rapidly  checks 
a  urethral  discharge,  but  the  gonococci  persist  in  the  urethra  much 
longer  than  when  the  silver  salts  are  used. 

Keyes  describes  the  method  of  Janet:  "He  irrigates  the  anterior 
urethra  twice  a  day  for  three  or  four  days,  then  increases  the  interval 
from  twelve  to  eighteen  hours.  When  the  cloudiness  of  the  first  urine 
is  pretty  well  gone  he  makes  the  interval  twenty-four  hours.  When  the 
discharge  is  no  longer  purulent  he  makes  it  forty-eight  hours. 

"When  the  second  urine  becomes  cloudy  he  irrigates  the  posterior 
urethra  according  to  the  same  method,  twice  a  day  at  first,  later  every 
day  or  every  other  day.  For  each  irrigation  of  the  posterior  or  ante- 
rior urethra  he  employs  500  c.c.  of  fluid  at  a  temperature  of  110°  F. 

"  If  the  case  is  seen  before  the  appearance  of  marked  inflammatory 
symptoms  he  employs  a  1  to  500  solution  of  permanganate,  immediately 
followed  by  a  like  quantity  of  boric  acid  solution.  If  this  does  not 
prove  too  irritating  he  continues  at  this  strength  until  the  inflammation 
has  subsided  sufficiently  to  permit  intervals  of  thirty-six  to  forty-eight 
hours,  when  he  drops  to  1  to  4000  or  1  to  6000  permanganate  and 
omits  the  boric  acid. 

"If  the  posterior  urethra  becomes  inflamed  he  begins  irrigating  it 
with  solutions  of  1  to  4000  down  to  1  to  10,000.  If  these  are  well  borne 
he  increases  the  strength  to  1  to  3000  or  1  to  1000  and  follows  it  with  a 
boric  acid  irrigation. 

"If  the  patient  is  first  seen  after  the  appearance  of  acute  inflam- 
matory symptoms  the  irrigation  is  begun  at  1  to  10,000  to  1  to  4000 
strength,  and  only  for  the  anterior,  even  if  the  posterior  urethra  is 
inflamed.  He  begins  treatment  of  the  posterior  urethra  only  when  the 
anterior  inflammation  is  under  control. 


TREATMENT  OF  GONORRHEA  321 

"In  the  declining  stage  he  gives  a  daily  irrigation  of  1  to  0000  to 
1  to  8000." 

Other  Methods. — Valentine  and  the  other  followers  of  the  Janet 
method  in  this  country  adopt  his  treatment  with  certain  variations. 
They  usually  employ  much  weaker  solutions  (1  to  4000  to  1  to  20,000) 
and  larger  quantities  (1000  e.c.  or  more),  and  often  irrigate  the  posterior 
urethra  every  day  or  every  other  day  as  a  routine  measure. 

The  method  in  which  this  Janet  irrigation  is  used  is  the  following: 

The  solution  is  put  in  a  wall  tank  which  can  be  easily  raised  or 
lowered  (the  height  is  about  three  feet  above  the  level  of  the  patient) ; 
from  the  lower  part  of  the  tank  runs  a  rubber  tube,  on  the  end  of  which 
is  a  blunt-glass  or  soft-rubber  urethral  nozzle. 

There  are  two-way  nozzle  devices  by  which  a  continuous  inflow  and 
outflow  may  take  place.  The  best  way,  however,  is  to  allow  the  urethra 
to  fill  up  \\iih  the  fluid,  then  withdraw  the  nozzle  and  allow  the  fluid  to 
flow  out.  Instead  of  the  wall  tank  a  hand  syringe  may  be  used. 

CASE  II. — Acute  Anterior  and  Silent  Posterior  Gonorrhea. — Patient 
came  with  his  second  gonorrhea.  His  discharge  of  three  days'  duration 
contained  many  gonococci  (methylene-blue  stain).  Meatus  is  red- 
dened. First  urine  cloudy;  second  urine  clear.  This  case  was  put  on 
exactly  the  same  treatment  as  Case  I.  In  three  weeks  he  had  only  pus 
shreds  in  his  clear  first  urine;  in  some  of  these  shreds  typical  gonococci 
were  found.  I  increased  the  strength  of  his  anterior  injection  to  1 
per  cent,  protargol,  and  then  because  this  caused  no  burning  to  2 
per  cent.  The  shreds  still  persisting,  I  changed  the  injection  to 
astringent  zinc  and  lead*  and  inquired  carefully  as  to  the  patient's 
getting  up  at  night  to  urinate  (generally  the  first  hint  of  a  posterior 
urethritis).  Finally,  because  of  the  persistence  of  the  urethritis,  I 
gently  felt  his  prostate,  which  was  not  enlarged,  but  I  massaged  from 
it  pus  cells  (page  310). 

His  anterior  urethritis  had  crept  back  into  his  posterior  urethra 
without  giving  the  usual  disturbance  to  urination,  and  the  prostatic 
involvement  was  the  cause  of  his  persistent  urethritis.  Because  his 
prostate  was  not  enlarged,  and  because  of  the  mildness  of  the  urethritis, 
I  did  not  immediately  put  the  patient  on  prostatic  rubs,  but  instead 
gave  him  bladder  washes  (every  second  day)  of  0.5  per  cent,  protargol 
for  once  or  twice  and  then  silver  nitrate  solution,  1  to  10,000  at  first, 
increasing  until  1  to  2000  is  used.  This  increase  in  strength  occurred 

*  Astringent  Injections — These  are  used  in  the  anterior  urethra  -(as  a  hand  injection) 
in  subacute  arid  chronic  anterior  gonorrhea  and  in  non-gonorrheal  urethritis.  The  one 
most  used  by  me  is 

R — Zinc  sulphatis 0.25  gr.  iv 

Liq.  plumbi  subacetatis  dil .      100.00  ^  iij 

Sig. — Shake.     Inject  morning  and  night. 

Other  solutions  are  zinc  sulphate  1  to  500  to  1  to  100;  potassium  permanganate  1  to 
3000  to  1  to  5000.  There  are  many  others.  They  are  held  in  the  urethra  about  half  a 
minute.  It  is  well  to  remember  that  both  astringent  injections  and  silver  salt  injections 
may  keep  up  a  urethral  discharge.  If  the  discharge  does  not  diminish  or  cease  when 
hand  injections  are  used  totally  withdraw,  for  a  time  at  least,  these  injections. 

M  u     i—21 


322  IM-'KCTIOXS  OF    URETHRA   AND  PROSTATE 

in  about  four  or  five  washes.  The  patient  should  have  after  each 
silver  wash  a  slight  feeling  of  warmth  in  the  urethra,  but  no  vigorous 
burning. 

After  the  third  or  fourth  silver  wash  the  patient's  urine  completely 
cleared.  In  a  week  he  was  pus-free  (both  morning  urine  and  urine 
passed  after  prostatic  massage)  and  in  four  weeks  his  complement- 
fixation  test  was  negative. 

CASE  III. — Acute  Anterior  and  Posterior  Gonorrhea. — The  patient 
came  with  the  second  gonorrhea  (twenty-four  hours'  duration,  seven 
days' incubation) ;  burning  on  urination;  no  frequency;  smear  showed 
pus  cells  and  gonococci  (methylene  stain);  first  urine  cloudy;  second 
clear.  His  treatment  was  anterior  injections  of  0.5  per  cent,  prb- 
targol  and  compound  salol  capsules. 

The  patient,  instead  of  using  a  urethral  syringe,  used  an  eye  dropper 
to  inject  himself.  This  resulted  in  trauma  of  the  urethra  with  bleeding 
and  a  rapid  extension  to  the  posterior  urethra,  which  extension  was 
revealed  by  clouding  of  the  second  glass  of  urine  and  by  the  patient's 
getting  up  twice  at  night  to  urinate  and  increased  pain  on  urination. 
Injections  were  stopped  temporarily.  His  pain  grew  much  less.  In 
one  week  he  was  again  put  on  anterior  injections  of  protargol.  Within 
two  weeks  his  urine  became  clear  and  contained  but  few  pus  shreds. 
Bladder  irrigations  of  silver  nitrate  1  to  10,000  were  very  gently  started. 
After  two  or  three  of  these  his  urine  was  absolutely  clear  and  massage 
of  the  prostate  showed  no  pus  in  the  prostatic  secretion. 

One  month  later  his  complement-fixation  test  was  negative. 

CASE  IV. — Acute  Anterior  Gonorrhea  and  Acute  Prostatitis. — The 
patient  had  a  urethral  discharge  five  days;  two  days'  incubation.  This 
is  the  second  gonorrhea ;  the  first  occurred  eight  years  ago  and  lasted 
months  because  of  many  exacerbations.  First  urine  cloudy;  second 
urine  clear.  Slight  discharge  contains  rare  pus  cell,  a  few  of  which 
are  filled  with  gonococci  (methylene-blue  stain).  Meatus  not  red. 
This  is  apparently  a  new  gonorrhea.  Because  of  the  slight  amount  of 
pus  in  his  first  urine  (an  active  case  usually  has  a  cloudy  urine  on  the 
fifth  day),  and  because  of  a  short  incubation,  it  was  thought  that  this 
might  be  an  exacerbation  of  an  old  gonorrhea;  so  his  prostate  was 
gently  massaged  and  in  the  discharge  a  few  pus  cells  were  found  (by  a 
few  pus  cells  is  meant  eight  to  ten  to  the  field,  using  one-fifth  objective) 
and  here  and  there  a  number  of  leukocytes  were  clumped  together. 
I  still  was  in  doubt  as  to  whether  or  not  this  was  a  new  gonorrhea. 
So  I  took  a  complement-fixation  test,  which  would  be  positive  if  it  were 
a  reinfection.  His  test  was  negative. 

He  was  treated  with  great 'care  because  of  the  difficulty  in  curing 
his  first  attack.  The  case  was  treated  as  Case  I,  and  at  the  end 
of  three  weeks  his  urine  was  clear,  with  a  rare  shred  and  no  gonococci 
found. 

He  was  seen  infrequently  now,  and  at  the  end  of  six  \veeks  his  urine 
still  remained  clear.  Because  of  the  old  attack  a  sound  (24  F.)  was 
gently  passed  into  the  bladder  to  learn  the  condition  of  his  urethra. 


TREATMENT  OF  GONORRHEA  323 

Much  bleeding  resulted,  from  granulations  in  his  bulb  left  by  the  first 
gonorrhea.  Thereupon  he  developed  a  severe  posterior  urethritis  and 
prostatitis,  due  to  the  sounding  and  the  extension  of  his  uncured 
anterior  gonorrhea  into  his  posterior  urethra.  Profuse  discharge;  first 
and  second  urines  cloudy;  prostate  large,  hot  and  tender.  Urinated 
every  hour,  day  and  night,  with  much  pain. 

He  was  put  on  the  palliative  treatment  of  prostatic  abscess.* 

This  patient  used  hot  rectal  irrigations  very  frequently;  also  morphin 
to  control  the  pain.  More  than  once  I  was  moved  to  suggest  operation 
on  his  prostate  because  of  the  intense  pain,  which  was  more  or  less 
continuous  for  two  weeks. 

I  put  him  on  vaccines  in  the  second  week,  but  they  had  little  effect 
(in  another  case,  less  acute,  vaccines  seemed  to  control  the  pain).  He 
had  no  chills,  and  his  temperature  kept  around  101°  F. 

At  last,  however,  the  pain  broke.  Then  he  was  put  on  sandalwood  oil 
and  rectal  irrigations  but  once  a  day.  This  was  continued  for  a  week. 
Now  rectal  irrigations  were  stopped.  He  was  kept  on  a  balsam  for 
nearly  three  months,  during  which  time  he  had  slight  exacerbations  of 
prostatic  pain  and  pus  in  his  urine.  At  the  end  of  three  months  his 
urine  was  clear,  rare  pus  shred,  no  gonococci  found.  Complement- 
fixation  test  positive.  Therefore  gentle  massage  of  his  prostate  twice  a 
week  was  began ;  at  first  without  irrigation,  and  later  with  potassium 
permanganate  solution  1  to  5000  in  his  bladder  (by  catheter).  Two 
months  later  his  blood  became  doubtful,  which  meant  cure. 

CASE  V. — Prostatic  Abscess. — The  patient  came  with  a  history  of  an 
acute  exacerbation  of  an  old  posterior  gonorrhea.  He  had  a  slight 
discharge  which  contained  extracellular  gonococci  (methylene-blue 
stain)  but  not  sufficiently  typical  to  be  called  gonococci;  so  a  Gram 
stain  was  made.  This  showed  gonococci.  He  had  much  pain  in  his 

*  Palliative  Treatment  of  Prostatic  Abscess. 

1.  Rest  in  bed  and  daily  catharsis. 

2.  Stop  all  urethral  injections. 

3.  Rectal  douche. 

By  means  of  hot  (rarely  cold)  water  applied  rectally,  acute  inflammation  of  the  pros- 
tate, prostatic  pain  and  vesical  tenesmus  are  often  controlled.  Any  two-way  tube  (one 
for  inflow  and  one  for  outflow)  which  may  be  introduced  into  the  rectum  for  an  inch  or 
two  suffices.  The  most  satisfactory  is  the  Chetwood.  This  costs  about  $1.50  and  is  made 
of  glass.  A  single  rectal  tube,  such  as  comes  with  an  enema  outfit,  may  be  used.  With 
this  hot  or  cold  water  is  allowed  to  flow  into  the  rectum;  then  by  disconnecting  the  tube 
the  water  is  allowed  to  flow  out  again,  and  so  on.  The  bag  containing  the  water  should 
be  two  or  three  feet  above  the  level  of  the  anus.  With  any  apparatus  a  number  of  trials 
on  the  part  of  the  patient  are  necessary  to  get  the  tube  working  properly:  The  seat  of 
the  toilet  is  the  best  place  for  administering  the  therapy.  At  least  two  quarts  of  water 
should  be  used  either  at  as  hot  a  temperature  as  can  be  borne  by  the  hand,  or  as  cold  as 
runs  from  the  tap.  A  teaspoonful  of  salt  may  be  added  to  the  pint.  This  salt  solution 
is  supposed  to  be  non-irritating.  Such  irrigations  should  be  given  as  often  as  three  times 
a  day,  if  the  patient's  acute  symptoms  demand  it;  otherwise  not  as  often.  Hot  irriga- 
tions are  always  tried  first,  and  if  these  have  no  effect  on  the  prostatic  pain,  or  urinary 
frequency,  change  to  cold. 

4.  Hyoscyamus  mixture  or  morphin  to  alleviate  the  painful  urination. 

5.  If  the  patient  has  complete  retention  of  urine,  he  should  be  gently  catheterized 
three  times  a  day.     It  is  probably  better  not  to  follow  the  catheterism  with  a  bladder 
wash.    If  a  bladder  wash  is  given,  however,  a  very  mild  antiseptic  solution  should  be 
injected  through  the  catheter  and  allowed  to  flow  out  and  the  catheter  then  removed. 


324  IXFECTIOXS  OF    URETHRA   AND   PROSTATE 

prostate;  he  urinated  day  and  night,  every  three-quarters  of  an  hour; 
prostate  large  and  irregular  and  periprostatic  tissues  infiltrated;  tem- 
perature 99°  F. ;  no  residual  urine.  He  was  put  on  the  palliative  treat- 
ment of  prostatic  abscess. 

The  following  week  his  temperature  steadily  rose  until  it  reached 
103°  F.  He  had  much  pain  in  the  urethra  and  in  both  groins.  At  the 
end  of  this  week  his  prostatic  abscess  was  drained  through  the  urethra  ;* 
no  free  pus  obtained,  but  broken-down  material  evacuated  from  his 
prostate. 

He  went  home  on  the  sixth  day  after  operation.  Before  going  home 
his  testicles  were  well  strapped  up;  notwithstanding  this  he  had  an 
epididymitis  which  responded  to  rest  in  bed  and  heat.  His  perineal 
fistula  rapidly  healed,  and  he  was  left  alone  for  two  months,  when  pus 
was  found  in  his  prostate  and  his  complement-fixation  test  was  posi- 
tive. 

Notwithstanding  bi-weekly  rubs  of  his  prostate,  followed  by  perman- 
ganate potassium  (1  to  4000)  in  his  bladder,  a  positive  complement- 
fixation  test  persisted  for  six  months. 

Treatment  was  given  up  after  three  months  and  he  was  told  to  get 
himself  in  good  physical  condition  and  to  depend  upon  this  to  rid  him 
of  his  last  gonococci.  His  complement-fixation  test  was  finally 
negative. 

CASE  VI. — Acute  Anterior  and  Posterior  Gonorrhea;  Acute  Gonorrheal 
A  rthritis. — The  patient  came  with  "a  history  of  his  second  gonorrhea  (two 
weeks'  duration)  complicated  by  an  acute  general  arthritis  which  began 
two  days  previously.  His  arthritis  was  mostly  in  the  small  bones  of  the 
feet.  His  very  profuse  discharge  contained  gonococci ;  first  and  second 
glasses  very  cloudy.  Meatus  very  small  (about  12  F.).  This  was 
immediately  cut  to  24  F.,  and  just  behind  the  meatus  was  the  opening 
of  a  perimeatal  gland  from  which  pus  could  be  squeezed.  The  duct 
ran  just  under  the  mucous  membrane  of  the  urethra.  This  duct  was 
opened  up  so  that  its  cavity  communicated  freely  with  the  urethra. 

Because  of  this  slight  operation,  which  gave  free  drainage  for  the 
gonorrheal  pus,  the  arthritis  immediately  cleared  up  and  the  patient's 
gonorrhea  promptly  improved.  Within  two  weeks  he  was  put  on  a 
protargol  anterior  injection  and  sandalwood-oil  capsules.  In  two  weeks 
he  had  only  a  morning  drop,  with  clear  urine  and  shreds  in  the  first. 
A  sound  was  passed  to  the  posterior  urethra  and  caused  undue  bleeding 

*  Operative  Indications  and  Operation  for  Prostatic  Abscess. — If  the  complete  retention 
is  not  relieved  in  a  very  few  days,  if  the  temperature  remains  persistently  above  100°  F., 
if  there  are  chills,  then  the  prostatic  abscess  should  be  operated  upon. 

Operation. — The  urethra  is  opened  by  perineal  section.  (See  Chap.  XI.)  The  index 
finger  is  introduced  into  the  prostatic  urethra  and  the  other  index  finger  introduced  into 
the  rectum  and  the  lobes  of  the  prostate  palpated  between  them.  The  lobes  of  the  pros- 
tate are  now  entered  by  the  urethral  finger  and  any  abscess  cavity  evacuated.  If  the 
abscess  has  broken  beyond  the  confines  of  the  prostate  and  has  pointed  in  the  perineum, 
wide  incision  and  drainage  are  indicated.  A  perineal  drainage  tube  is  inserted  into  the 
bladder  and  removed  in  twenty-four  hours.  A  patient  can  often  leave  the  hospital  in  a 
week.  He  must  be  careful,  however,  as  epididymitis  often  follows  indescretions.  The 
perineal  wound  should  heal  in  three  or  four  weeks. 


TREATMENT  OF  GONORRHEA  325 

in  the  bulb,  where  a  slight  constriction  was  found.     The  24  F.  sound 
was  grasped  on  withdrawal. 

His  posterior  urethra  was  therefore  irrigated  every  other  day  with 
silver  nitrate  solution  beginning  1  to  10,000  and  reducing  to  1  to  2000. 
This  course  was  followed  to  accustom  the  urethra  to  instrumentation 
so  that  the  Kollman  dilator  or  sounds  could  be  used.  These  were 
indicated  because  of  the  slight  strictures  and  granulations  which  were 
found  by  the  sound.  He  was  stretched  with  a  Kollman  dilator 
twice  (to  30  F.  then  to  34  F.,  an  interval  of  one  week  between 
stretchings).  This  cured  him. 

CASE  VII. — Persistent  Complement-fixation  Long  after  an  Apparent 
Cure. — This  patient  came  with  an  acute  anterior  gonorrhea.  In  one 
month  his  urine  was  clear;  there  were  a  few  pus  cells  in  his  prostate. 
He  was  told  to  return  for  a  complement-fixation  test.  He  did  not 
return  until  nearly  two  years  later,  when  he  wished  the  test  preparatory 
to  marriage.  In  the  interval,  as  far  as  I  could  ascertain,  he  had  no 
symptoms  and  no  new  attacks  of  gonorrhea.  He  had  a  very  few  pus 
cells  in  his  prostate;  no  gonococci  were  found  in  these,  but  his  comple- 
ment-fixation was  positive.  A  positive  complement-fixation  persisting 
as  long  as  this  means  that  the  patient  harbors  gonococci.  His  prostate 
was  massaged  but  three  or  four  times;  the  massage  was  followed  by 
bladder  irrigations;  one  month  later  his  complement-fixation  was 
doubtful  and  one  month  later  negative.  This  shows  the  extraordinary 
efficiency  of  prostatic  massage  in  some  cases;  all  cases  do  not  react  to 
massage  as  well  as  this! 

CASE  VIII. — Gonococcal  Reinfection  of  the  Urethra. — The  patient  had 
a  urethra!  discharge  for  four  days.  This  was  his  third  gonorrhea ;  the  last 
one  occurred  one  year  previous.  Incubation  of  this  attack  one  day; 
meatus  not  red.  No  burning  on  urination.  Discharge  showed  one  or 
two  cells  which  contained  gonococci.  He  gave  a  history  of  a  number  of 
these  attacks,  each  of  short  incubation.  Because  of  this  history,  and 
because  he  had  not  had  a  red  meatus,  and  because  of  the  difficulty  to 
find  typical  gonococci  in  the  discharge,  it  was  thought  that  this  was 
a  reinfection  of  the  urethra  from  an  old  prostatic  gonorrhea.  His 
prostate  was  gently  rubbed,  therefore,  and  the  drop  of  pus  expressed 
from  it  showed  typical  gonococci.  He  was  put  on  anterior  injections 
of  protargol  which  within  three  or  four  days  entirely  cleaned  up  his 
urethral  discharge.  Then  because  of  prostatic  infection,  a  catheter 
was  very  gently  introduced  into  his  bladder  and  0.5  per  cent,  protargol 
injected,  and  the  patient  passed  this  out.  As  this  gave  no  reaction,  his 
prostatic  massage  was  gently  begun,  followed  by  a  mild  permanganate 
bladder  wash,  1  to  4000.  A  month  of  this  (twice  a  week),  with  the 
prostatic  massage  increasing  in  severity,  cleared  his  prostate  of  pus,  and 
a  month  later  his  complement-fixation  test  was  negative. 

CASE  IX. — Peri-urethral  Abscess. — This  case  came  with  a  history  of 
gonorrhea  of  two  weeks.  For  three  days  he  had  a  swelling  on  the 
under  surface  of  the  penis  two  inches  back  of  the  end.  This  was 
evidently  a  gonorrheal  abscess  of  a  peri-urethral  gland.  It  was  defin- 


326  INFECTIONS  OF   URETHRA  AND  PROSTATE 

itely  pointing  and  was  incised*  the  pus  evacuated  and  the  urethra 
wrapped  in  a  wet  bichloride  dressing.  No  urethral  treatment  was  given 
until  the  abscess  healed — about  two  weeks.  Then  the  treatment  did 
not  differ  from  that  of  any  anterior  gonorrhea. 

CASEX. — Non-gonorrheal  Prostatitis  and  Infection  of  the  Verumon- 
tanwn. — This  patient  came  with  a  morning  urethral  discharge  which 
had  persisted  since  his  second  attack  of  gonorrhea  two  years  previous. 
His  urine  was  clear  and  contained  many  shreds.  When  a  discharge  per- 
sists for  this  length  of  time  it  generally  means  a  prostatitis.  Therefore 
his  prostate  was  examined.  His  prostatic  secretion  showed  much  pus. 
Blood  for  complement-fixation  was  negative  for  gonococcal  infection. 
This  was  therefore  a  comparatively  harmless,  postgonorrheal  pros- 
tatitis. The  prostate  was  rubbed  twice  a  week.  Each  rub  was 
followed  by  an  instillation  of  silver  nitrate  (0.25  to  0.5  per  cent.)  or  a 
potassium  permanganate  bladder  wash  1  to  4000  or  1  to  5000.  These 
were  continued  for  a  month,  changing  occasionally  to  the  Kollman 
dilator.  His  discharge  by  this  time  was  reduced  to  a  morning  drop, 
which  no  slight-of-hand  of  mine  seemed  to  be  able  to  cure.  I  urethro- 
scoped  him  and  found  a  large  and  boggy  verumontanum.  This  was 
probably  the  explantion  of  his  infection,  so  I  burned  it  with  acid 
nitrate  of  mercury.  The  discharge  still  persisted,  however,  and  I 
apparently  was  unable  to  cure  it. 

CASE  XL — Postgonorrheal  Neurosis. — Patient  came  complaining  of  a 
pain  in  his  deep  urethra.  He  had  a  gonorrhea  seven  years  previous  and  a 
second  one  five  years  later  which,  because  of  the  above  pain,  he  believed 
still  persisted.  His  urine  was  clear  and  contained  a  very  large  number  of 
shreds  which, under  the  microscope,  showed  no  pus.  He  has  few  pus  cells 
in  his  prostate.  A  year  previous  his  blood  gave  a  negative  complement- 
fixation  test.  Urethroscopic  examination  shows  a  few  papillomata  just 
back  of  the  verumontanum.  These  were  destroyed  by  touching  them 
with  acid  nitrate  of  mercury.  When  he  was  examined  again  three 
weeks  later  his  papillomata  were  cured,  but  his  pain  was  still  present. 
This  is  characteristic  of  these  cases.  Even  if  the  cause  for  a  neurosis 
is  found  and  removed  the  symptoms,  especially  that  of  pain  in  the 
urethra,  very  often  persist  indefinitely. 

CASE  XII. — Cured  Gonorrhea.- — This  patient  came  asking  for  guaran- 
tee of  cure  from  a  gonorrhea  which  he  had  five  years  ago.  His  present 
urine  was  absolutely  clear;  no  shreds.  The  urine  passed  after  vigorous 
massage  of  the  prostate  and  vesicles  showed  on  centrifuging  absolutely 
no  pus.  He  was  guaranteed  to  be  free  without  a  complement-fixation 
•test. 

CASE  XIII. — Incrustation  of  the  Urethra  Causing  Urethral  Discharge. 
—The  patient  came  because  of  a  slight  morning  urethral  discharge 

*  Operative  Treatment  for  Peri-urethral  Abscess. — These  abscesses  are  allowed  to  point 
and  then,  under  aseptic  precautions  and  local  anesthesia,  are  incised.  The  incision  is 
parallel  to  the  course  of  the  urethra,  wide,  and  extends  down  to  the  bottom  of  the  abscess. 
Unless  these  peri-urethral  abscesses  are  the  result  of  a  stricture  or  prostatic  abscess,  no 
perineal  section  with  drainage  of  the  bladder  is  necessary. 


TREATMENT  OF  GONORRHEA  327 

containing  pus  and  epithelial  cells,  but  no  gonococci;  his  complement- 
fixation  test  was  negative,  and  there  was  no  pus  in  a  drop  massaged 
from  his  prostate.  He  was  stretched  with  the  Kollman  dilator  and 
the  bladder  irrigated  with  various  solutions — permanganate  1  to  4000, 
silver  nitrate  1  to  2000,  and  he  was  given  instillations  of  0.5  per  cent, 
silver  nitrate.  All  of  this  had  no  effect  on  his  urethral  discharge.  He 
was  then  urethroscoped  and  in  his  bulb  were  a  few  ulcers  of  the  mucous 
membrane  with  calcareous  deposits  on  them.  These  were  scraped  off 
with  a  cotton  swab  and  the  ulcers  touched  up  with  10  per  cent,  silver 
nitrate  (through  the  urethroscope) .  His  discharge  immediately  stopped 
and  he  was  cured. 

Vaccines  and  Vaccine  Therapy. — The  fact  that  gonorrhea  is  in  most 
cases  a  localized  and  not  a  general  infection  explains  the  reason  why 
vaccines  are  rarely  used  with  success  in  combating  this  disease.  The 
more  general  the  gonorrhea,  the  more  hope  of  success  of  any  vaccine 
therapy.  Thus  cases  of  gonorrheal  arthritis  should,  and  often  do,  yield 
to  vaccines;  while  cases  of  epididymitis  or  prostatitis  rarely  show 
improvement. 

Nevertheless  in  some  intractible  cases  of  both  prostatitis  and  epidi- 
dymitis it  is  well  to  try  the  effect  of  vaccines. 

Because  different  strains  of  gonococci  are  used  to  prepare  the  antigen 
used  in  the  complement-deviation  test,  it  is  plausible  that  a  vaccine 
prepared  from  different  strains  of  gonococci  might  work  better  than  a 
one-strain  vaccine.  Many  prefer  such  a  "polyvalent"  vaccine  and 
report  favorable  results  from  its  use. 

Another  method  is  to  try  on  both  animals  and  patients  the  efficacy 
of  vaccines  made  of  different  strains  of  gonococci  and  use  the  strain 
which  proves  most  efficacious. 

Dosage.- — Always  start  with  a  very  small  dose,  because  we  do  not 
know  how  a  particular  individual  is  going  to  react. 

A  ^onococcal  vaccine  is  used  in  which  1  c.c.  equals  100,000,000  to 
500,000,000  of  dead  gonococci. 

Begin  with  1  to  20,000,000  and  repeat  every  fourth  day,  gradually 
increasing  the  dose  according  to  the  way  a  patient  reacts. 

Autogenous  Vaccines. — Many  prefer  these  to  regular  stock  vaccines. 
The  objection  to  them  is  that  it  takes  some  time  to  have  them  made  up. 
Their  dosage  is  the  same  as  that  of  stock  vaccines. 

Antigonococcus  Serum. — Rogers  and  Torry  have  derived  from  rams  a 
polyvalent  serum  which  has  been  used  in  cases  of  gonorrheal  arthritis 
and  epididymitis.  Two  c.c.  of  this  serum  are  injected  every  second  or 
third  day,  generally  intramuscularly. 

Those  using  the  serum  report  much  the  same  result  as  those  using 
vaccines.  The  serum  injections,  unlike  the  injection  of  the  vaccines, 
may  be  followed  by  redness  and  swelling  at  the  point  of  injection,  chills 
and  temperature. 

To  sum  up,  both  vaccines  and  sera  are  uncertain  in  their  action; 
generally  have,  as  nearly  as  can  be  determined,  absolutely  no  result; 
and  rarely,  only  too  rarely,  achieve  a  brilliant  cure. 


328  IXFECTIOXS  OF    i  RET  11 R A   AXD   PROSTATE 

TREATMENT  OF  SEMINAL  VESICULITIS. 

The  treatment  is  non-surgical  and  surgical.  The  rum-surgical  means 
of  curing  a  seminal  vesiculitis  are  similar  to  those  for  curing  a  prosta- 
titis.  Rectal  injection  of  hot  water;  massage  of  the  seminal  vesicles 
(with  great  care  if  the  condition  is  at  all  acute),  urethral  washes  to  get 
rid  of  the  debris  massaged  out  of  the  vesicles,  etc. 

Squier  classifies  the  indications  for  surgical  treatment  under  three 
headings — pus,  pain  and  rheumatism. 

1.  Under  the  first  he  includes  (a)  the  acute  cases,  developing  in  the 
course  of  gonorrhea,  often  mistaken  for  prostatic  abscess,  in  which  the 
perivesiculitis  simulates  prostatic  enlargement;  (6)  cases  of  recurrent 
epididymitis  following  acute  urethritis  and  vesiculitis;  (e)  cases  of 
chronic  vesiculitis  which  simulate  spermatorrhea;  and  (d)  those  in 
which  the  discharge  from  the  urethra  occurs  during  defecation  and 
those  in  which  non-operative  treatment  has  been  faithfully  carried  out. 

2.  Under  pain  he  includes  various  referred  symptoms  (p.  313).     He 
reserves  surgery,  for  cases  which  resist  local  treatment. 

3.  In  the  rheumatic  group  he  includes  acute,  subacute,  chronic,  and 
the  deforming  types  of  arthritis  in  which  a  definite  relationship  can  be 
determined  between  the  joint  and  the  vesicle. 

Cabot  reserves  operation  for  cases  of  crippling  arthritis. 

Operations. — I  shall  again  follow  Caulk  in  describing  the  operations 
on  the  vesicles.  These  may  be  divided  into: 

"  Vasotomy  with  injections  of  the  vesicles,  vesiculotomy,  and  vesic- 
ulectomy.  Yasotomy,  heralded  by  Belfield,  has  been  employed  by 
him  in  many  cases  of  vesiculitis.  It  does  not  at  present  seem  to  have  a 
substantial  hold  on  the  profession  in  the  surgery  of  these  organs.  He 
has  reported  excellent  results  and  others  have  corroborated  his  state- 
ments. The  technic  is  simple,  consisting  in  making  a  small  scrotal 
vasotomy  and  allowing  argyrol,  collargol,  or  some  other  solution  te  find 
its  way  into  the  cavities  of  the  vesicles.  Owing  to  its  simplicity  it  seems 
to  be  an  operation  which  should  be  more  frequently  employed,  and 
seems  indicated  particularly  in  many  of  the  cases  of  chronic  discharges 
which  are  not  benefited  by  local  treatment. 

"  Seminal  vesiculotomy  and  vesiculectomy  may  be  performed  either 
perineally  or  through  the  ischiorectal  region.  The  perineal  approach 
is  by  far  the  most  commonly  employed.  The  usual  steps  are  as  follows : 
with  the  patient  in  the  lithotomy  position,  a  Y-shaped  incision  is  made 
similar  to  Young's  perineal  incision  for  prostatectomy;  the  apex  of  the 
prostate  is  exposed,  then  there  are  various  modifications  by  different 
men.  In  order  to  bring  down  the  vesicles,  Young  uses  a  tractor  similar 
to  the  one  he  employs  in  prostatectomy  work,  excepting  that  it  is  longer 
and  passes  directly  into  the  bladder  from  the  meatus.  By  means  of 
rotating  this  instrument  against  the  symphysis,  he  is  able  to  bring  the 
vesicles  nicely  into  the  wound,  and  he  is  at  liberty  to  undertake  what- 
ever he  deems  necessary. 

Squier,  after  exposing  the  apex  of  the  prostate,  and  by  traction,  is 


TREATMENT  OF  SEMINAL   VESICULITIS  329 

able  to  pull  the  vesicles  down  for  a  satisfactory  exposure.  After  the 
apex  of  the  prostate  has  been  exposed,  and  either  the  tractor  or  the  tape 
is  inserted,  the  prostate  is  brought  into  the  wound  and  the  rectum 
separated,  dissection  being  between  the  two  layers  of  Denonvillier's 
fascia.  When  the  vesicles  are  exposed  they  will  be  found  to  be  covered 
by  the  same  fascial  layers  between  the  two  layers  which  cover  the 
prostate.  These  must  be  divided  before  the  vesicles  can  be  attacked. 
After  division  of  the  fascia,  the  prostate  vesicles  and  vas  can  be 
examined.  There  is  usually  a  perivesicular  exudate  which  occasionally 
makes  exposure  difficult.  One  can  then  open  and  drain  the  vesicles  in 
any  place  desired,  or  can  remove  any  part  of  the  vesicular  wall  which 
may  be  indicated.  It  is  very  frequently  necessary  also  to  incise  the 
ampulla  of  the  vasa.  This  operation  should  be  used  on  both  vesicles 
and  vasa.  After  one  has  incised  the  vesicles,  the  operation  may 
be  considered  complete,  or  the  prostate  may  also  be  drained  at  the  same 
time  if  it  seems  advisable.  Tubes  and  gauze  drainage  are  used.  The 
gauze  should  be  placed  in  the  incised  cavities  and  the  tube  down 
to  this  point.  The  wound  is  partially  closed  by  bringing  together 
the  levator  and  muscles  with  catgut,  and  the  skin  with  either  catgut 
or  silk. 

In  Fuller's  operation  for  seminal  vesiculotomy  the  patient  is  placed 
in  the  knee-chest  position,  thigh  and  knees  sharply  flexed,  the  knees 
well  separated.  He  makes  a  cut  on  either  side  of  the  anus,  taking 
care  not  to  injure  the  sphincter.  The  forefinger  is  inserted  into  the 
rectum,  and  acts  as  a  guide  to  prevent  injury  to  the  rectum.  The 
levator  ani  muscles  are  cut;  then  the  space  between  the  prostate  and 
rectal  wall  is  dissected  bluntly  with  the  finger,  and  the  tip  of  the  seminal 
vesicle  exposed.  Along  a  grooved  director  passed  to  the  vesicle,  the 
vesicle  is  incised.  The  cavities  of  the  vesicles  are  packed  with  gauze. 
Fuller  has  done  this  operation  about  200  times. 

Operations  on  the  Vas  Deferens. — If  the  operation  for  relief  of  sterility 
following  double  epididymitis  (p.  328)  is  excepted,  the  two  principal 
operations  on  the  vas  are  vasotomy  and  vasectomy.  Vasotomy  has 
been  employed  by  Belfield,  Cabot  and  others  for  the  injection  of  silver 
salts  into  the  seminal  vesicles  for  the  treatment  of  various  affections  of 
these  sacs.  The  vas  is  grasped  between  the  finger  and  thumb,  and 
raised  until  it  is  just  underneath  the  scrotal  skin.  The  skin  is  excised 
over  it,  and  the  vas  exposed. 

Vasotomy  is  unnecessary  in  most  cases  because,  with  very  little 
practise,  a  fine  needle  may  be  inserted  into  the  lumen  of  the  vas,  and 
fluid  injected  without  incision. 

Vasectomy  has  been  used  on  men  so  old  as  to  have  lost  the  power  of 
procreation,  and  who  have  recurrent  attacks  of  epididymitis  secondary 
to  infection  of  the  posterior  urethra  and  bladder.  The  incision  is 
the  same  as  in  vasotomy,  and  both  of  these  operations  may  be  done 
under  local  anesthesia. 

Vasectomy  has  also  been  suggested  and  used  for  the  sterilization  of 
criminals  and  the  unfit. 


330  INFECTIONS  OF   URETHRA  AND  PROSTATE 

GONORRHEAL  EPIDIDYMITIS. 

Acute  gonorrheal  epididymitis  is  the  most  frequent  complication  of 
posterior  urethral  gonorrhea,  and  is  also  the  most  frequent  disease  of 
the  testicle.  This  disease  is  important  because  it  not  infrequently 
results  in  obliteration  of  the  vas  deferens,  thereby  preventing  sperma- 
tozoa from  reaching  the  seminal  vesicles  and  urethra.  If  the  disease 
is  bilateral  and  severe  enough  to  cause  obliteration  of  both  vasa  de- 
ferentia,  sterility  results. 

Etiology. — Jjonorrheal  epididymitis  is  always  preceded  by  a  posterior 
gonorrheal  urethritis;  while  this  posterior  urethritis  is  generally  acute, 
it  need  not  necessarily  be  so.  The  epididymitis  may  simply  occur  in 
the  course  of  a  posterior  urethritis,  or  more  often  is  caused  by  improper 
instrumentation  (passage  of  a  sound,  etc.),  or  the  trauma  following 
prostatic  massage.  Trauma  of  the  testicle,  itself,  may  be  a  predis- 
posing factor.  It  occurs  in  from  20  to  30  per  cent,  of  all  cases  of 
gonorrhea,  although  one  is  apt  to  see  it  much  more  often  in  clinics  than 
in  private  practice.  "  When  the  epididymitis  precedes  the  urethral  dis- 
charge, as  it  sometimes  does,  we  have  to  do  probably  with  a 
relapsing  gonorrhea  and  not  with  a  new  infection."  (Keyes.) 

Pathology. — The  inflammation  running  down  the  vas  deferens  attacks 
the  glob  us  minor  first;  it  may  stop  here,  but  it  generally  goes  on  and 
attacks  the  globus  major.  The  seminiferous  tubes  are  swollen,  edema- 
tous  and  infiltrated;  abscess  formation  is  rare;  resolution  generally 
takes  place.  According  to  the  length  and  the  severity  of  the  inflamma- 
tion, more  or  less  fibrous  tissue  is  formed.  Many  tubules  may  be 
obliterated  and  the  lumps  in  the  epididymitis  may  take  a  number  of 
months  to  finally  resolve.  The  testicle  proper  is  practically  never 
involved. 

Symptoms. — Local  Symptoms. — The  testicle  presents  all  the  evidences 
of  acute  inflammation :  Swelling,  often  redness,  edema  of  the  skin  and 
tenderness.  Because  the  infection  travels  down  the  vas,  the  pain  and 
swelling  are  generally  first  felt  in  the  tail  of  the  epididymis;  thence  the 
swelling  may  extend  to  the  head  of  the  epididymis  and  back  along  the 
cord.  The  swelling  of  the  cord  often  causes  very  intense  pain  because 
of  its  strangulation  in  the  external  abdominal  ring.  After  a  number 
of  days,  sometimes  a  week  or  more,  the  pain  and  swelling  subside.  Not 
infrequently  acute  epididymitis  of  the  opposite  side  follows,  but  both 
testicles  are  very  rarely  involved  at  the  same  time.  The  urethral  dis- 
charge and  cloudy  urine  may  entirely  clear  up  during  the  course  of  the 
epididymitis  and  may  recur  again  with  the  fading  of  the  inflammation. 
In  a  certain  number  of  cases,  however,  acute  epididymitis  causes  a 
temporary  cessation  of  the  urethral  discharge.  Relapses  occur  in  a 
number  of  cases. 

General  Symptoms. — These  are  fever,  generally  not  above  100°  F.,  and 
the  other  constitutional  symptoms  of  a  mild  infection. 

Diagnosis. — When  a  patient  has  a  gonorrhea  which  is  followed  by 
acute  epididymitis  the  diagnosis  is  not  difficult.  Occasionally,  how- 


GONORRHEAL  EPIDIDYMITIS  331 

ever,  when  the  epididymitis  is  subacute,  it  is  difficult  to  differentiate 
it  from  a  tuberculosis  or  a  colon  bacillus  infection  of  the  epididymis. 
Careful  examination  of  the  centrifuged  urine  for  the  gonococcus,  the 
colon  bacillus  or  tubercle  bacillus  and  palpation  of  the  prostate  and 
seminal  vesicles  help  to  determine  the  nature  of  the  process.  In 
certain  rare  cases  the  use  of  tuberculin  for  diagnosis  probably 
assists. 

Beer*  cites  one  case  in  which  a  distinct  focal  reaction  followed  the 
injection  of  tuberculin.  The  epididymis  became  more  swollen  and  pain- 
ful. The  writer  has  lately  had  a  case  which  gave  a  general  tuberculin 
reaction  which  was  followed  by  no  focal  reaction  in  the  involved 
epididymis.  This  epididymitis  eventually  cleared  up  and  was  prob- 
ably a  colon  infection. 

The  complement-fixation  test  should  not  be  neglected  in  making  the 
diagnosis;  it  is  invariably  sooner  or  later  positive  (generally  within  two 
weeks  after  the  beginning  of  the  epididymitis).  Syphilitic  testicle, 
malignant  disease  of  the  testicle,  and  other  rarer  conditions  are  to  be 
thought  of. 

Prognosis. — Death  rarely  is  caused  by  gonorrheal  epididymitis;  there 
are,  however,  a  few  fatal  cases  recorded  in  which  death  from  peritonitis 
or  pyemia  followed. 

Watson  and  Cunningham f  quote  Benzla  who  "  investigated  the  num- 
ber of  offspring  begotten  by  the  soldiers  of  the  German  Army  who  had 
had  gonorrhea,  and  found  that  10.5  per  cent,  of  those  who  had  the 
disease  without  epididymitis  were  childless,  while  of  those  who  had 
unilateral  epididymitis  23.4  per  cent,  were  childless,  and  those  with 
bilateral  epididymitis  41.7  per  cent,  were  childless."  Keyes  states  that 
"  patients  who  have  recurrent  attacks  of  epididymitis  are  less  likely  to 
be  sterile  than  those  who  have  but  a  single  attack."  The  reason  for 
this  is  obvious.  If  the  epididymitis  has  closed  the  vas  deferens  in 
the  first  attack,  the  gonococci  cannot  again  come  through  the  vas  and 
cause  a  second  attack. 

Treatment. — The  first  prophylactic  measure  is  to  prevent  if  possible 
an  anterior  gonorrhea  from  extending  into  the  posterior  urethra.  The 
second  is,  if  posterior  gonorrhea  has  become  established,  to  be  cautious 
and  gentle  in  entering  the  posterior  urethra  with  instruments.  During 
the  acute  stage  of  the  gonorrhea  no*  instrument  should  be  put  into  the 
urethra,  and  the  prostate  should  not  be  massaged.  A  suspensory  is  also 
advised,  but  it  is  a  question  wrhether  it  ever  prevent's  the  occurrence  of  an 
epididymitis.  When  once  the  epididymis  is  inflamed  the  following  meas- 
ures should  be  taken.  The  patient  should  be  put  to  bed  and  kept  there  until 
the  temperature  is  normal  and  acute  pain  has  subsided.  The  testicles 
should  be  elevated  as  much  as  possible.  To  do  this  a  suspensory  bandage 
or  jock-strap  is  inadequate.  Alexander  improvised  the  following  suspen- 


*  The  Use  of  Tuberculin  in  the  Diagnosis  of  Obscure  Conditions  of  the  Genito-urinary 
Tract,  Mod.  Record,  October  11,  1913. 

t  Genito-Urinary  Diseases,  Lea  &  Febiger,  190S. 


:;:;i)  IXFECTIOX*  or  I-RETIIUA  AND  PROSTATE 

sory,  which  is  still  used  at  Bellevue Hospital.  A  broad  bandage  of  canton 
flannel  is  pinned  around  the  patient's  waist.  The  cross  bar  of  a  T-band- 
age  is  made  of  folded  gauze  and  is  2  feet  long  by  5  inches  wide.  The 
vertical  portion  of  the  T  is  divided  into  two  muslin  strips  each  2  inches 
wide  by  2  feet  long ;  these  are  used  as  permeal  straps.  The  gauze  portion 
is  pinned  snugly  around  the  scrotum  and  penis, the  permeal  straps  pinned 
to  the  waistband,  behind,  and  the  testicles  are  elevated  by  pinning  the 
ends  of  the  gauze  to  the  waistband.  As  far  as  I  know  this  is  the  only 
method  by  which  the  testicles  can  be  properly  elevated,  and  is  much 
better  than  the  old  method  of  placing  a  broad  band  of  adhesive  plaster 
across  the  thighs  and  allowing  the  testicles  to  rest  on  this.  External 
application  of  heat  or  cold  may  be  applied  to  the  testicle.  This  appar- 
ently does  not  particularly  influence  the  inflammation  but  lessens  the 
pain.  The  same  is  true  of  applications  of  various  irritative  drugs  applied 
to  the  scrotum.  A  favorite  one  is  50  per  cent  guaiacol  in  glycerin;  this 
relieves  the  pain  but  I  doubt  if  it  hastens  the  recovery.  It  irritates 
the  scrotal  skin. 

Barney*  has  devised  a  rubber  bandage  which  is  so  placed  around  the 
testicle  as  to  exert  a  uniform  pressure  on  it.  The  author  believes  this  is 
the  best  method  of  treating  acute  gonorrhea!  epididymitis. 

Vaccines. — Many  recommend  vaccines  beginning  with  20,000,000 
bacteria  and  repeating  every  second  day  in  ascending  doses.  Occa- 
sionally they  do  good,  but  more  often  not. 

Operative  Treatment. — Hagner  first  suggested  the  following  operation 
for  acute  epididymitis: 

"At  the  juncture  of  the  swollen  epididymis  and  testicle,  an  incision 
6  cm.  to  10  cm.  in  length,  depending  upon  the  amount  of  enlargement, 
is  made  through  the  scrotum  down  to  the  tunica  vaginal  is,  which  is 
opened  at  the  juncture  of  the  epididymis  and  testicle.  After  the  serous 
membrane  is  opened,  all  the  fluid  is  evacuated  and  the  enlarged  epidi- 
dymis examined  through  the  wound.  The  testicle,  with  its  adnexa,  is 
delivered  from  the  tunica  vaginalis  and  enveloped  in  warm  towels. 
The  epididymis  is  then  examined  and  multiple  punctures  made  through 
its  fibrous  covering  with  a  tenotome,  especially  over  those  portions 
where  the  enlargement  and  thickening  are  greatest.  The  knife  is 
carried  deep  enough  to  penetrate  the  thickened  fibrous  capsule  and 
enter  the  infiltrated  connective  tissue.  "^Yhen  the  knife  is  through  the 
thickened  covering  of  the  epididymis,  a  very  marked  lessening  of  re- 
sistance will  be  felt.  If  pus  be  seen  to  escape  from  any  of  the  punctures, 
the  opening  is  enlarged  and  a  small  probe  inserted  in  the  direction 
from  which  the  pus  flows.  By  this  method,  I  believe  there  is  less 
danger  of  injuring  the  tubes  of  the  epididymis  than  by  cutting  with  the 
knife.  After  the  probe  is  passed  in,  pus  will  be  evacuated  by  light 
massage  in  the  region  of  the  abscess,  and  a  fine-pointed  syringe  is  used 
to  wash  out  the  cavity  with  1  to  1000  bichloride  of  mercury,  followed 

*  Acute  Gonorrheal  Epididymitis  Treated  by  the  Method  of  Bier,  Boston  Medical  and 
gurgical  Journal,  October  28,  1909. 


NON-GONORRHEAL   URETHRITIS  333 

by  physiological  salt  solution.  The  testicle  is  then  restored  to  its 
normal  position,  and  in  every  case  the  tunica  vaginalis  is  thoroughly 
washed  with  1  to  1000  bichloride,  followed  by  normal  salt  solution. 
The  incision  of  the  tunica  vaginalis  is  lightly  closed  with  a  running 
catgut  suture;  a  cigarette  drain  of  gauze  is  then  laid  over  the  incision, 
the  skin  being  brought  together  with  a  subcutaneous  silver-wire 
suture,  the  cigarette  drain  passing  out  at  the  lower  angle  of  the 
wound." 

This  operation  is  to  be  considered  only  in  extremely  acute  cases.  It 
has  not  as  yet  been  determined  whether  the  operation  increases  or 
decreases  the  occurrence  of  sterility. 

Declining  Stage. — Various  methods  of  hastening  the  resorption  of 
the  exudate  have  been  suggested,  such  as  strapping  the  testicle  with 
adhesive  plaster  or  with  a  rubber  bandage.  Personally  I  believe  that 
just  as  good  results  are  achieved  by  using  Alexander's  Bellevue  bandage 
for  a  week  or  two  after  the  acute  inflammation  has  subsided.  No  ure- 
thral  injection,  or  instrumentation  should  be  used  until  a  number  of 
weeks  have  elapsed,  as  these  may  cause  an  acute  exacerbation  of  the 
epididymitis. 

Recurrent  Attacks. — Acute  gonorrheal  epididymitis  is  not  often  com- 
plicated by  acute  recurrences.  These  are  much  more  often  seen  in 
epididymitis  occurring  with  hypertrophy  of  the  prostate  and  infection 
of  the  posterior  urethra  and  bladder.  Recurrent  attacks  of  epididy- 
mitis may  be  treated  precisely  as  the  original  attack. 

Sterility  in  Bilateral  Gonorrheal  Epididymitis. — In  sterile  marriages 
the  fault  lies  with  the  male  in  over  15  per  cent,  of  the  cases,  and  in 
probably  most  of  these  there  is  azoospermia  due  to  chronic  epididymitis 
of  the  globus  minor,  and  occlusion  of  the  ducts  leading  to  the  vas.  For 
these  cases  Martin7  introduced  the  operation  of  epididymovasotomy. 
An  anastomosis  is  made  between  the  vas  deferens  and  the  head  of  the 
epididymis.  The  testicle  is  exposed,  together  with  the  epididymis,  and 
the  nearby  vas.  A  portion  of  the  globus  major  is  incised,  from  which 
incision  spermatic  fluid  will  ooze.  This  should  contain  motile  sperma- 
tozoa. If  spermatozoa  are  not  found  at  the  first  incision,  various  other 
incisions  should  be  made  in  the  globus  major  until  spermatozoa  are 
found.  The  vas  is  incised  longitudinally,  and  its  lumen  opened.  The 
edges  of  this  incision  are  sewed  to  the  edges  of  the  wound  in  the  epidi- 
dymis. Martin  uses  fine  silver  wire,  and  fine  needles  for  the  suture. 
Naturally  such  an  operation  is  deferred  until  any  disease  of  the  urethra 
or  seminal  organs — strictured  urethra,  prostatitis,  seminal  vesiculitis — 
is  cured. 

It  is  probably  better  to  operate  upon  one  side  first  rather  than  on  both 
sides  simultaneously.  If  the  operation  be  a  success,  then  the  second 
one  need  not  be  done.  To  ensure  the  patency  of  the  vas  deferens, 
argyrol  may  be  injected  into  the  cut  vas  at  the  time  of  operation.  If 
the  argyrol  appears  in  the  urine,  the  vas  is  patent. 


334  INFECTIONS  OF   URETHRA  AND  PROSTATE 

GONOCOCCAL  INFECTION  OF  THE  BLADDER  AND  KIDNEYS. 

In  spite  of  the  frequency  of  gonorrhea  of  the  male  urethra  gonorrheal 
cystitis  or  pyelonephritis  is  extremely  rare.  The  gonorrhea  seems  to 
stop  at  the  internal  urethral  orifice  or  the  trigone.  The  only  case  of 
gonorrheal  cystitis  that  I  have  seen  was  in  a  woman.  Here  the  gono- 
cocci  evidently  reached  the  urethra  in  virulent  form  and  the  patient 
passed  nearly  pure  blood  for  two  or  three  days.  There  are  probably 
not  more  than  twenty  cases  of  gonorrheal  pyelonephritis*  in  the  litera- 
ture. In  symptoms  it  does  not  differ  from  any  other  pyelonephritis,  and 
the  diagnosis  is  made  by  finding  gonococci  in  the  specimen  of  urine 
obtained  from  the  kidney. 

NON-GONORRHEAL  URETHRITIS. 

Postgonorrheal  Urethritis. — A  patient  may  have  all  of  the  symptoms 
of  a  urethritis  after  the  gonococci  have  disappeared  from  his  urethra. 
This  is  caused  primarily  by  damage  to  the  urethra  by  the  gonococcus 
and  secondary  infection  by  some  other  organism  (see  Bacteriology). 
The  symptoms  are  those  of  a  chronic  gonorrheal  urethritis  only  the 
gonococcus  is  not  present.  The  complications  are  limited  to  a 
prostatitis  or  seminal  vesiculitis. 

Traumatic  Urethritis. — There  are  a  great  many  causes  for  this: 
Instrumentation,  passage  of  a  stone,  introduction  of  caustic  injections 
by  mistake,  or  with  the  idea  of  aborting  a  gonorrhea,  crushing  the  penis, 
or  bending  the  erect  organ.  Such  a  urethritis  is  often  followed  by 
permanent  damage  to  the  urethra,  and  stricture. 

Syphilitic  Urethritis. — The  urethra  may  be  the  site  of  a  chancre 
which  may  be  entirely  overlooked  until  the  secondary  syphilitic 
eruption  appears.  The  only  symptoms  may  be  those  of  a  mild 
urethritis,  discharge,  urethral  burning,  etc. 

Secondary  syphilitic  inflammation  of  the  urethra  as  well  as  of  the 
bladder  and  even  the  kidney  have  been  described.  These  are  generally 
in  the  form  of  mucous  patches. 

Herpetic,  Eczematous,  Diathetic,  and  Ingestive  Urethritis. — The 
first  may  occur  in  eczematous  patients,  with  an  exacerbation  of  an 
eczematous  attack.  Patients  with  gout,  patients  with  an  attack  of 
grippe,  and  diabetic  patients  may  have  symptoms  of  urethritis,  which 
occurs  during  an  acute  exacerbation  of  the  disease.  Alcohol,  can- 
tharides,  arsenic,  purgative  mineral  waters,  iodide  of  potash,  tur- 
pentine, asparagus,  have  all  been  accused  of  lighting  up  a  mild  urethral 
inflammation. 

Treatment. — The  treatment  of  all  these  forms  of  urethritis  consists  in 
removing  their  cause  and  then  treating  them  as  one  would  a  chronic 
gonorrheal  urethritis,  giving  preference  to  astringents.  Vaccines 
apparently  do  no  especial  good. 

*  E.  MacD.  Stanton11  gives  the  bibliography  of  these  cases  in  an  article,  "A  Clinical 
and  Histopathological  Study  of  the  Gonococcal  Infection  of  the  Kidney." 


NON-GONORRHEAL   URETHRITIS  335 

Is  a  Non-gonorrheal  Urethritis  a  Bar  to  Matrimony? — This  is  more 
or  less  of  an  unsolved  problem.  It  is  reasonable  to  suppose  that  a 
woman  may  be  infected  by  these  non-gonorrheal  organisms,  which 
infection  may  cause  vaginitis,  which  inflammation  might  possibly 
cause  a  woman  to  become  sterile.  Indeed,  I  have  seen  a  case  of  a 
violent  but  short-lived  vaginitis  of  this  sort  follow  shortly  after  marriage. 
The  husband  had  a  non-gonorrheal  urethritis  and  stricture.  Most 
urologists  believe,  however,  that  a  man  with  a  non-gonorrheal  urethritis 
can  marry  and  that  no  trouble  will  follow.  It  seems  to  be  the 
consensus  of  opinion  that  the  gonococcus  alone  is  responsible  for 
endometritis,  salpingitis,  etc. 

Urethrorrhea,  Prostatorrhea,  Spermatorrhea. — The  causes  for  these 
conditions  are  various.  Masturbation  is  always  put  first;  undue 
sexual  excitement  is  another  cause  assigned.  Often  they  are 
postgonorrheal. 

The  symptoms  are  a  mucous  discharge  from  the  urethra,  either  con- 
stant or  only  during  defecation.  The  discharge  may  contain  simply 
mucous  or  may  contain  prostatic  cells  or  spermatozoa.  Their  principal 
importance  lies  in  the  fact  that  the  occurrence  of  the  discharge  makes 
the  patient  think  he  has  "  lost  his  manhood"  or  is  being  much  weakened 
by  this  sexual  drain. 

Keyes  says  that  "the  only  cure  is  common  sense,  the  only  relief 
matrimony."  Hygiene,  exercise  in  the  open,  getting  the  patient's 
thoughts  off  his  sexual  apparatus,  and  keeping  him  away  from  a 
physician  are  all  indicated. 

BIBLIOGRAPHY. 

1.  Caulk:  Surg.,  Gynec.  and  Obst.,  November,  1915. 

2.  Finger,  Gohm,  and  Schlagenhaufer:  Arch.  f.  Derm.  u.  Syph.,  1894,  xxviii,  277 

3.  Flexner:  Prostitution  in  Europe. 

4.  Henry:  The  Military  Surgeon,  May,  1912,  xxx,  520. 

5.  Keyes:  Am.  Jour.  Med.  Sc.,  1912. 

6.  Lowsley:  Anatomy  of  the  Human  Prostate  Gland,  Tr.  Am.  Med.  Assn.,  1915; 
January,  1913. 

7.  Martin:   University   of   Pennsylvania  Med.  Bull.,    March,    1902;   Thera.    Gaz., 
December,  1909. 

8.  McNeil:  Archives  of  Pediatrics,   September,    1913. 

9.  Poroz:  Anatomy  of  the  Prostate,  Folia  Urologica,  May,  1914. 

10.  Schwartz  and  McNeil:  Am.  Jour.  Med.  Sc.,  May,  1911. 

11.  Stanton:  Urolog.  and  Cut.  Rev.,  November  2,  1913,  i. 


CHAPTER  X. 
DISEASES  OF  THE  URETHRA  IX  THE  FEMALE. 

BY  A.  T.  OSGOOD,  M.D. 

ANATOMY  OF  THE  FEMALE  URETHRA. 

THE  female  urethra,  unlike  that  of  the  male,  has  a  solely  urinary 
function.  In  contrast  with  the  urethra  of  the  male,  it  is  a  short,  wide 
channel  analogous  to  the  membranous  portion  of  the  male  urethra. 

This  canal  is  a  tube  of  approximately  cylindrical  shape  whose  length 
is  3.5  cm.  (2.5  to  5  cm.),  and  whose  wall  is  0.5  cm.  in  thickness,  begin- 
ning at  the  outlet  of  the  bladder  and  extending  almost  vertically 
downward,  when  the  woman  stands  erect,  to  the  vestibule  of  the 
vagina.  The  diameter  of  the  lumen  of  the  urethra  is  about  8  mm. 
(7  to  10  mm.)r~ 

~The  mucous  membrane  of  the  urethra  is  thrown  into  longitudinal 
folds  when  at  rest  by  contraction  of  the  surrounding  muscles,  so  that  a 
transverse  section  of  its  lumen  presents  a  median  point  from  which 
radiating  lines  diverge  between  these  folds  like  the  spokes  of  a  wheel — 
the  picture  presented  at  the  extremity  of  a  straight  examining  tube 
(urethroscope). 

The  epithelium  of  this  lining  mucous  membrane  is  of  the  stratified 
squamous  type,  except  near  the  bladder,  where  it  takes  on  the  character 
of  the  bladder  mucosa,  which  bears  transitional  epithelium.  In  the 
inner  third  of  the  canal  the  mucosa  presents5  many  small  tubular  glands, 
while  the  outer  portion  contains  fewer,  more  widely  scattered,  and 
somewhat  larger  glands.  On  each  side  of  the  external  urethral  orifice, 
usually  just  within  the  canal,  are  found  the  openings  of  the  para-urethral 
ducts  (the  largest  of  which  are  called  Skene's  glands).  These  ducts 
may  open  upon  the  vestibule  outside  of  the  mucous  membrane  of  the 
urethra. 

The  mucous  membrane  often  pouts  somewhat  at  the  external  urethral 
meatus  upon  the  vestibule  of  the  vagina,  forming  a  slight  eminence. 
The  external  orifice  is  found  in  varied  forms;  commonly  it  assumes  the 
shape  of  an  inverted  Y  by  reason  of  the  prominence  of  a  longitudinal 
fold  upon  its  floor.  It  is  seen  as  a  vertical  slit  with  prominent  margins 
or  as  a  dimple  or  depression  in  the  eminence  with  radial  folds  in  its 
lining  membrane.  The  prominent  folds  of  mucous  membrane  upon 
the  margins  of  the  meatus  may  overlie  the  orifice  in  such  a  way  as  to 
conceal  the  lumen,  so  that  in  a  child  or  adult  with  small  vulva  and 
intact  hymen,  careful  observation  is  needed  to  detect  the  lumen  of  the 
canal. 

(336) 


ANATOMY  OF   THE  FEMALE   URETHRA  337 

The  submucosa  is  a  stratum  of  loose  areolar  tissue,  separating  the 
epithelial  layer  from  the  innermost  (longitudinal)  muscular  layer,  con- 
taining elastic  fibers  and  a  network  of  cavernous  venous  spaces  which 
form  a  spongy,  erectile  tissue.  The  mucous  membrane  with  its 
numerous  longitudinal  folds  is  a  cylinder  within  the  cylinder  com- 
prising the  muscular  sheath,  and  is  loosely  connected  with  it  by  the 
submucosa. 

Subjacent  to  this  submucosa  is  a  sheath  or  cylinder  of  longitudinal 
smooth  muscle  fibers,  thin  near  the  bladder  and  thicker  near  the  ex- 
ternal orifice.  Outside  of  the  longitudinal  smooth  muscle  layer  is  the 
second  layer  of  smooth  muscle  fibers  which  are  arranged  in  circular  or 
ring  fashion  about  the  tube.  This  circular  layer  is  of  importance,  for  its 
upper  portion  surrounds  the  beginning  of  the  urethra  at  the  vesical 
outlet  to  form  the  involuntary  sphincter  of  the  bladder,  which  must  be 
considered,  as  Kalisher1  has  plainly  demonstrated,  not  as  a  part  of  the 
bladder  musculature,  but  as  a  urethra!  muscle  extending  into  and 
forming  a  part  of  the  smooth  muscle  underlying  the  trigone  of  the 
bladder  (sphincter  trigonalis,  lissosphincter  internus).  This  circular 
layer  of  smooth  muscle  is  thick  and  well  defined  about  the  inner  one- 
third  of  the  urethra,  extending  obliquely  about  the  urethra  from  its 
anterior  surface  downward  and  backward  to  form  the  muscular  layer 
of  the  trigonum  vesicse.  About  the  rest  of  the  urethra  it  forms  a  cylin- 
drical sheath,  becoming  thinner  as  it  approaches  the  external  urethral 
orifice. 

These  smooth  muscle  layers  are  not  voluntarily  controllable,  and  are 
innervated  by  nerve  fibers  from  the  pelvic  ganglions  of  the  sympathetic 
hypogastric  plexus. 

The  third  and  most  important  of  the  muscle  layers  surrounding  the 
urethra  is  the  outermost  striated,  voluntary  muscle  the  "sphincter 
urogenitalis,"  or  compressor  urethrse  muscle,  which  is  found  between 
the  two  lay  ere  of  the  triangular  ligament  of  the  perineum. 

These  striated  fibers  surround  completely  only  the  upper  portion  of 
the  urethra  above  the  urethro vaginal  septum,  where  bands  interlace 
both  in  front  of  and  behind  the  urethra  to  form  a  ring  muscle.  Some 
fibers  extend  upward  beneath  the  urethra  toward  the  bladder  in  a  longi- 
tudinal direction.  Where  the  urethral  and  vaginal  walls  run  parallel 
the  fibers  of  this  muscle  do  not  decussate  below  the  urethra  in  the 
urethrovaginal  septum,  but  extend  downward  on  each  side  to  end 
in  the  lateral  aspects  of  the  vagina.  The  anterior  extremity  of  the 
urethra  near  the  orifice  is  not  surrounded  by  the  sphincter  urogenitalis 
muscle,  i.  e.,  that  part  of  the  canal  in  front  of  the  anterior  layer  of 
the  triangular  ligament  of  the  perineum.  The  anterior  layer  of  the 
triangular  ligament  serves  to  suspend  and  fix  the  urethra  in  the 
subpubic  angle.  This  striated  muscle,  sphincter  urogenitalis,  or 
compressor  urethrse  is  innervated  through  branches  of  the  pudic 
nerve.  The  urethra  may  be  divided  for  description  into  two2  parts. 
1 .  This  portion  extends  from  the  bladder  wall  to  the  point  where  it 


338  DISEASES  OF  THE   URETHRA  IX   THE  FEMALE 

meets  the  urethro vaginal  septum — the  urethra  libera.  This  portion, 
measuring  about  1  cm.  in  length,  is  surrounded  by  areolar  tissue  which 
loosely  fills  the  surrounding  space  between  the  symphysis  pubis  (2  cm. 
anterior  to  the  urethra)  and  the  anterior  vaginal  wall  behind.  On  each 
side  of  this  urethra  libera  the  anterior  (mesial)  margins  of  the  levator 
ani  muscles  pass  down  close  to  the  urethra,  passing  the  vaginal  wall  as 
well,  to  reach  insertion  in  the  rectal  wall,  median  perineal  tendon,  and 
external  anal  sphincter. 

This  free  portion  of  the  female  urethra  is  surrounded,  as  in  a  sling, 
by  the  posterior  fibers  of  the  sphincter  urogenitalis  or  compressor 
urethne  muscle.  Some  of  the  fibers  of  this  muscle  run  upward  in  a  lon- 
gitudinal direction  upon  the  posterior  surface  of  the  urethra  toward  the 
bladder.  This  is  the  only  part  of  the  female  urethra  completely  sur- 
rounded by  fibers  of  this  voluntary  muscle. 

This  portion  of  the  urethra  surrounded  by  the  internal  involuntary 
sphincter  muscle  and  these  circular  fibers  of  the  compressor  urethrse 
muscle  are  particularly  liable  to  injury  by  pressure  of  the  child's  head 
during  delivery,  and  lead  to  the  discomforts  of  incontinence  so  com- 
monly found  in  women  who  have  borne  children. 

2.  The  second  (lower)  portion  of  the  urethra  is  that  part  extending 
from  the  point  where  the  free  portion  of  the  urethra  and  the  vagina 
come  into  relation  to  form  the  urethro  vaginal  septum.  This  is  the 
vaginal  portion  of  the  urethra,  and  measures  approximately  2^  cm.  in 
length.  The  compressor  urethrse  muscle  extends  around  the  anterior 
and  lateral  walls  of  this  part  of  the  urethra  without  extending  into  the 
urethro  vaginal  septum  beneath  the  canal. 

The  course  of  the  urethra  from  the  bladder  to  the  vestibule  of  the 
vagina  follows  a  slight  curve  beneath  the  symphysis  pubis,  whose  con- 
cavity is  directed  anteriorly,  and  the  canal  is  separated  from  the 
symphysis  about  1 .5  to  2  cm.  In  the  erect  posture  (standing  or  sitting) 
the  course  of  the  urethra  is  nearly  vertical,  while  in  the  dorsal  position, 
as  during  examination,  it  is  practically  horizontal,  and  its  slight  curve 
can  be  disregarded  clinically. 

In  passing  a  straight  instrument,  such  as  a  urethroscopic  tube,  it  is 
in  fact  more  comfortable  for  the  patient  and  simpler  for  the  surgeon  if 
no  attempt  is  made  to  follow  the  gentle  curve.  The  tip  of  the  instru- 
ment by  this  method  impinges  against  the  less  sensitive  superior  wall 
and  glides  smoothly  into  the  bladder. 

The  inferior  (posterior)  urethral  wall  lies  upon  the  median  line  of  the 
anterior  vaginal  wall,  but  separated  from  it  by  tissue  of  0.5  or  1  cm. 
in  thickness,  which  is  called  the  urethro  vaginal  septum,  consisting  of 
dense  connective  tissue  containing  elastic  and  muscle  fibers. 

The  internal  urethral  orifice  is  found  normally  at  the  lowest  point  of 
the  bladder.  The  vesical  trigone  is  less  marked  than  in  man,  and  the 
ridge  called  the  uvula  vesicse  is  usually  absent,  so  that  the  shape  of  this 
orifice  is  nearly  round.  It  lies  2.5  cm.  posterior  to  the  lower  half  of  the 
symphysis  pubis. 

The  external  urethral  orifice  lies  in  the  sagittal  plane  of  the  vestibule 


PHYSIOLOGY  OF  THE  FEMALE   URETHRA  339 

1  or  1.5  cm.  from  the  lower  margin  of  the  symphysis,  and  at  a  variable 
distance  from  the  vaginal  margin.  It  presents  diverse  forms  (sagittal 
cleft,  star,  triangular)  of  opening,  upon  a  more  or  less  well-defined 
papilla,  commonly  with  a  ridge  upon  the  lower  margin  or  floor,  which 
produces  the  inverted  Y-shape  in  many  cases.  This  is  the  narrowest 
portion  of  the  canal,  varying  in  size,  as  does  the  external  urethral 
meatus  in  man.  Skene's  ducts  and  a  varying  number  of  smaller 
para-urethral  ducts  open  upon  the  margin  of  the  external  meatus 
usually  in  the  sulci  between  the  median  fold  upon  its  floor  and  lateral 
walls.  These  ducts  are  of  particular  importance,  since  they  often 
are  the  lodging-place  of  prolonged  infection,  especially  that  produced 
by  the  gonococcus. 

The  blood  supply  of  the  urethral  tissues  arises  from  branches  of  the 
internal  pudic,  inferior  vesical,  and  vaginal  branch  of  the  uterine 
arteries.  Its  veins  pass  into  the  vesicovaginal  and  prevesical  or 
pudendal  plexuses.  About  the  upper  part  of  the  urethra  (neck  of 
bladder)  the  veins  in  the  submucosa  are  abundant,  giving  rise  to  the 
darker  color  of  the  mucosa  at  this  point. 

The  lymphatics  of  the  urethra  pass  to  nodes  of  the  hypogastric  chain 
and  to  nodes  in  the  inguinal  regions. 

Sensory  nerves  of  the  urethra  come  from  the  pudic  and  through  the 
sympathetic  nerves  of  the  pelvis. 

PHYSIOLOGY  OF  THE  FEMALE  URETHRA. 

The  female  urethra  is  the  channel  of  outlet  for  the  renal  secretion 
from  the  reservoir  called  the  urinary  bladder. 

The  ability  to  retain  fluid  in  the  bladder  depends  upon  muscular 
closure  of  the  tube.  Paralysis  of  these  muscles  results  in  inability  of 
the  bladder  to  retain  its  contents — incontinence. 

The  urethra  occupies,  therefore,  a  most  important  place  in  the 
function  of  urination.  The  musculature  of  the  bladder  undertakes  that 
part  of  this  function  which  embraces  the  storing  up  of  fluid  by  dilatation 
and  its  forcible  expulsion  by  contraction  of  the  detrusor. 

The  internal,  plain  muscle,  involuntary  sphincter  of  the  bladder 
surrounds  the  beginning  of  the  urethra  at  the  vesical  outlet.  Versari 
demonstrated  that  this  muscle  is  distinct  from  the  musculature  of  the 
bladder.  It  is  a  thickened  portion  of  the  circular  plain  muscle  layer 
of  the  urethra.  It  is  intimately  related  with  part  of  the  bladder 
(trigone  and  orifice)  and  with  part  of  the  urethra. 

Surrounding  the  urethra  at  a  lower  point  (i.  e.,  distal  to  this  in- 
ternal sphincter)  is  a  second  sphincter  of  striated  muscle  which  may 
be  held  in  contraction  through  voluntary  effort  to  close  the  canal 
and  retain  urine  in  the  bladder,  reinforcing  the  function  of  the  internal 
sphincter. 

"The  chief  physiological  factor  in  the  closure  of  the  urethra,  and 
therefore  in  the  normal  retention  of  urine,  is  the  internal  sphincter."2 
By  the  action  of  this  muscle,  urine  is  retained  in  the  bladder  of  the  dead 


340  DISEASES  OF   THE    URETHRA   IX   THE  FEMALE 

body,  and  in  the  living  the  tonic  contraction  of  the  internal  sphincter 
permits  the  accumulation  of  urine  in  considerable  amounts,  with 
periodic  evacuation. 

Kehfisch,  Hanc,  von  Zeissl  and  others  have  adduced  experimental 
evidence,  which  indicates  that  relaxation  of  the  internal  sphincter  pre- 
cedes the  contraction  of  the  detrusor  in  normal  urination,  and  is  the 
main  factor  in  the  process  of  micturition  incited  by  desire.  Lesions 
which  induce  dilatation  of  the  internal  sphincter  and  contraction  of  the 
detrusor  can  often  be  traced  to  that  area  within  the  urethra  which  is 
surrounded  by  the  internal  sphincter.  Failure  of  the  sphincters  to 
perform  their  function  of  control  of  urine  in  the  bladder  (incontinence) 
points  directly  to  some  defect  which  may  lie  within  the  canal  which 
these  muscles  are  designed  to  occlude,  or  to  failure  of  one  or  both 
of  the  sphincters  themselves,  to  produce  complete  closure  of  the 
outlet. 

The  sensation  of  desire  to  void  urine  is  doubtless  one  which  arises 
about  the  bladder  outlet  (often,  if  not  always,  in  the  lumen  of  the  ure- 
thra), and  normal  control  consists  not  only  in  contraction  of  the  external 
voluntary  sphincter,  but  in  accentuation  of  inhibitory  impulses  to  the 
spinal  centre  controlling  the  reflex  act  of  micturition,  so  that  efferent 
impulses  do  not  accomplish  complete  relaxation  of  the  internal  sphinc- 
ter, even  though  contractions  of  the  bladder  detrusor  may  be  so  strong 
as  to  be  painful. 

Interruption  of  the  act  of  urination  can  be  accomplished  by  woman 
as  well  as  by  man,  although  in  the  female  the  voluntary  sphincter  is  a 
weaker  muscle  and  does  not  embrace  the  urethra  so  completely  as  in  the 
male.  This  interruption  is  produced  by  contraction  of  the  internal 
involuntary  sphincter,  not  through  voluntary  control  of  this  muscle 
itself,  but  through  a  check  upon  the  reflex  in  the  spinal  cord  transmitted 
to  it  from  the  cerebrum. 

These  features  of  the  physiology  of  micturition  are  emphasized  be- 
cause of  their  important  bearing  upon  disturbances  of  function  and 
diseases  of  the  female  urethra. 

The  female  urethra  does  not  possess  the  highly  sensitive  structures  of 
the  prostatic  urethra,  yet  the  juxtavesical  portion  of  the  female  urethra 
is  its  most  sensitive  part,  and  stimulation  of  its  mucosa  induces  the 
desire  for  urination,  an.d  often  (if  not  always)  sets  in  action  the  spinal 
reflex  of  micturition. 

The  urethra  is  often  overlooked  or  disregarded  in  the  mechanism  of 
urination  when  its  importance  is  paramount.  Every  complaint  of 
painful  urination  should  focus  the  attention  of  the  investigator  upon 
the  urethra  as  the  seat  of  origin  of  this  symptom.  Abnormally  fre- 
quent urination  points  to  a  disturbance  of  the  sensory  nerves  ("  sense 
of  titillation")  in  the  grasp  of  the  internal  sphincter,  which  induces 
a  dilatation  of  this  muscle  and  a  reflex  contraction  of  the  bladder 
musculature. 

All  treatment  for  the  relief  of  abnormalities  of  the  function  of  urina- 
tion must  take  into  account  the  anatomical  structure  of  the  urethra 


EXAMINATION  OF   THE  FEMALE   URETHRA  341 

with  the  muscles  which  surround  it  and  the  physiological  action  of  these 
structures.  . 

The  function  of  urination  is  usually  ascribed  by  physiologists  to  the 
bladder,  so  that  clinical  application  of  these  physiological  studies  leads 
not  uncommonly  to  the  ascribing  of  all  changes  in  this  function  to 
abnormalities  in  the  bladder  itself,  while  the  all-important  urethra  is 
forgotten. 

MEANS  AND  METHODS  FOR  EXAMINATION  OF  THE  FEMALE 

URETHRA. 

Preparatory  to  examination  the  patient  should  present  herself  with- 
out voiding  urine  and  without  cleansing  the  vulva  by  bath  or  douche  for 
from  four  to  six  hours  preceding  the  time  of  examination. 

Urethral  instruments  must  be  sterilized  and  manipulated  with  all 
aseptic  precautions.  The  methods  for  sterilization,  etc.,  of  instruments 
is  elsewhere  considered. 

The  preparation  of  the  patient  consists  in  washing  the  vulva  with 
green  soap  and  water.  After  covering  with  sterile  towels  the  legs 
of  the  patient,  and  the  examining  table  where  contact  with  the 
hands  of  the  surgeon  or  with  instruments  is  possible,  drape  a  sterile 
towel  over  the  inner  side  of  each  thigh  so  that  its  inner  margin  falls  in 
the  median  line  of  the  vulva.  By  this  means  a  margin  of  towel  may  be 
used  to  retract  beneath  it  the  labia  minora  and  majora,  exposing  the 
vestibule  and  meatus  urinarius. 

The  meatus  and  vestibule  are  then  carefully  wrashed  with  a  solution 
of  bichloride  of  mercury  1  to  2000  or  other  antiseptic  solution. 

Instruments  are  lubricated  before  insertion  into  the  meatus  with  one 
of  the  numerous  soluble  colorless  jelly-like  lubricants  made  from  certain 
mosses  (K.  Y.  jelly,  etc.).  Glycerin  is  a  less  satisfactory  lubricant  and 
oily  substances,  such  as  olive  oil,  vaselin,  etc.,  are  very  undesirable, 
chiefly  because  they  befog  a  lens  or  electric-light  bulb. 

The  position  of  the  patient  for  this  examination  is  important,  and 
doubtless  the  best  from  the  stand-point  of  the  examiner  is  the  knee- 
breast  position,  because  in  this  position  the  abdominal  contents  fall 
downward  and  forward,  relieving  the  bladder  and  entire  pelvic  cavity 
of  pressure,  permitting  the  ingress  of  air  into  the  bladder  and  collecting 
the  urine  at  the  vertex  instead  of  the  base  as  it  escapes  from  the  ureters, 
thus  relieving  the  examiner  of  the  troublesome  outflow  of  urine  into  the 
urethroscopic  tube  during  examination  of  that  part  of  the  urethra  close 
to  the  vesical  outlet.  This  position,  however,  has  distinct  disad- 
vantages to  the  patient.  It  is  offensive  to  her  to  be  thus  exposed  and 
examined,  and  it  is  uncomfortable  and  fatiguing  after  a  short  time.  In 
some  cases,  however,  it  is  necessary  to  resort  to  this  position. 

The  common  dorsal  position,  as  for  gynecological  examination,  is 
usually  the  most  practicable  one  and  the  one  assumed  with  least  com- 
plaint on  the  part  of  the  patient.  Nine  out  of  ten  urethroscopic  exami- 
nations can  be  satisfactorily  made  with  this  position.  The  dorsal 


342  DISK  ASKS   OF    THE    I'RETJUIA    /.V    TIIK   FKMALK 

position  with  the  pelvis  elevated  and  the  body  supported  by  shoulder 
braces,  simulating  the  Trendelenburg  position,  is  sometimes  resorted 
to,  but  offers  only  slight  advantage. 

The  Sims  posture  is  often  very  satisfactory,  and  with  the  foot  of  the 
table  elevated  may  compare  with  the  knee-breast  position  in  favorable 
features.  The  Sims  position  frequently  has  to  be  used  when  stiffness  of 
the  hip  or  spine  (ankylosis,  old  fracture,  etc.)  interferes  with  the  dorsal, 
the  knee-breast,  or  knee-elbow  position. 

Inspection. — The  patient  is  placed  in  the  usual  dorsal  position,  with 
knees  separated  and  thighs  flexed,  as  for  any  gynecological  examination, 
and  the  labia  minora  are  gently  separated,  exposing  the  vestibule  and 
vaginal  orifice. 

By  careful  inspection  the  urethral  orifice  and  the  vestibule  may 
reveal  excessive  or  abnormal  secretion.  For  the  detection  especially  of 
inflammatory  changes  in  and  about  the  urethra  it  is  imperative  that  this 
inspection  shall  be  made  before  any  cleansing  of  the  vulva  has  been 
done  by  a  nurse  or  by  the  surgeon,  because  it  is  important  to  note 
whether  secretion  is  present  about  the  whole  vulva  (as  with  profuse 
vaginal  discharge),  whether  there  is  secretion,  swelling,  or  unusual 
redness  about  the  meatus,  the  para-urethral  ducts,  the  vulva  or  the 
vaginal  outlet  for  the  differentiation  of  a  generalized  purulent  infection 
from  an  isolated  lesion  in  or  in  connection  with  the  urethra. 

The  first  inspection  "should  note  the  size,  shape,  and  color  of  the 
meatus  and  of  the  vestibule  about  it  as  well  as  the  presence  or  absence 
of  secretion  and  the  source  of  secretion.  The  anterior  vaginal  wall 
should  be  seen,  when  possible,  to  detect  scars  beneath  the  urethra  or 
swelling  projecting  upon  this  surface. 

The  mouths  of  para-urethral  ducts,  usually  invisible  in  the  normal 
state,  may  sometimes  be  brought  into  view  by  displacing  the  lips  of  the 
urethra  or  gently  pressing  downward  upon  the  median  fold  upon  the 
floor  of  the  meatus.  If  these  ducts  harbor  an  infection  they  are  dis- 
tinguished as  red  points  about  the  size  of  the  head  of  a  pin.  The  most 
satisfactory  means  of  exposing  these  orifices  .of  Skene's  or  para-urethral 
ducts  to  view  is  that  proposed  by  Kelly,  using  two  probes  bent  to  the 
shape  of  hairpins,  or  two  hairpins  even,  which  can  be  satisfactorily 
sterilized  by  boiling,  to  serve  as  retractors. 

Palpation. — It  should  be  made  a  practice  always  to  palpate  upon 
the  vestibule  and  vaginal  orifice  with  pressure  toward  the  meatus  before 
pressure  is  exerted  upon  the  full  extent  of  the  urethra  per  vaginam 
since  the  external  urethral  meatus  may  be  the  seat  of  isolated  sensitive- 
ness or  induration  or  the  para-urethral  ducts  alone  may  be  the  source  of 
a  little  secretion. 

With  the  index  finger  in  the  vagina  so  that  its  pulp  is  in  contact  with 
the  median  portion  of  the  anterior  vaginal  wall,  pressure  is  exerted  upon 
the  urethra  from  the  bladder  floor  to  the  outermost  part  of  the  canal, 
in  an  effort  to  express  any  secretion  toward  the  meatus  and  to  note  the 
consistency  of  the  urethral  wall  and  determine  points  of  sensitiveness. 

Normally  the  urethral  canal  feels  like  a  rounded  tube  when  thus 


EXAMIXATIOX  OF   THE  FEMALE   URETHRA  343 

palpated  through  the  vagina.  It  moves  slightly  from  side  to  side  as  it 
rolls  beneath  the  finger,  and  no  complaint  of  pain  is  made  by  the  patient. 
Points  of  sensitiveness  are  often  valuable  signs,  pointing  the  way  to  the 
discovery  of  lesions  when  other  means  of  investigation  are  employed. 

Localized  indurations  or  dense  thickening  in  the  entire  wall  of  the 
urethra  with  immobilization  point  to  peri-urethral  inflammation  or  in- 
filtration. Localized  nodes  and  small  peri-urethral  abscesses  can  be 
better  defined  by  palpating  the  urethral  canal  per  vaginam  after  a 
solid  instrument,  such  as  a  sound  or  glass  or  silver  catheter,  has  been 
inserted  through  the  canal. 

This  instrument  affords  a  firm  body  against  which  the  urethral  wall  is 
pressed,  and  brings  into  prominence  abnormal  areas  against  the  pal- 
pating finger. 

Anesthetics. — The  urethra  is  highly  sensitive  as  compared  with  the 
bladder,  vagina,  or  rectum  and  anus.  Examination,  therefore,  to  be 
satisfactorily  carried  out  must  be  made  with  extreme  gentleness  and 
deftness.  Local  anesthetics  are  frequently  employed,  and  general 
anesthesia  is  necessary  when  very  painful  lesions  exist,  yet  in  the  ma- 
jority of  cases  no  local  or  general  anesthesia  is  used  for  examining  the 
urethra,  or  for  passing  catheter,  cystoscope,  or  other  instrumentation. 
It  is  better  to  use  no  anesthetic  which  so  changes  the  bloodvessels  by 
contraction  or  dilatation  that  the  color  of  the  mucous  membrane  is 
altered.  Cocaine  blanches  an  inflammatory  area  so  that  its  pathologi- 
cal redness  fades,  destroying  thereby  an  important  feature.  Cocaine  is 
so  surprisingly  toxic  to  some  individuals,  and  absorption  by  the  urethral 
mucosa  is  so  rapid  that  it  should  not  be  advocated.  It  is,  however,  the 
most  certain  of  all  our  local  anesthetic  drugs  for  allaying  pain. 

Novocain,  4  per  cent,  solution  or  weaker,  is  less  toxic  and  causes  less 
disturbance  of  the  natural  appearance  than  cocaine,  and,  while  less 
positively  analgesic,  is  commonly  very  satisfactory.  Alypin,  5  per  cent. 
or  10  per  cent,  solution,  is  commonly  used,  and  many  others  are  com- 
mended. 

Spinal  anesthesia  with  tropacocain  (dose  1  c.c.,5  per  cent,  solution) 
injected  through  the  third  or  fourth  lumbar  interspace  is  an  efficient 
and  useful  means  for  making  an  examination  of  the  urethra,  or  for 
treatment  of  urethral  conditions,  in  cases  impossible  to  examine  and 
treat  under  local  anesthesia.  The  general  anesthetics,  nitrous  oxide, 
nitrous  oxide  and  oxygen,  ether  and  chloroform  must  be  resorted  to  as 
indicated. 

In  highly  neurotic  subjects  or  in  cases  with  great  pain  the  preliminary 
employment  of  morphin,  morphin  and  atropin,  or  morphin  and 
scopolamin,  injected  hypodermic-ally,  is  useful. 

The  use  of  suppositories  of  opium  or  morphin  is  often  advantageous. 

To  anesthetize  the  urethra  with  a  local  anesthetic,  soak  a  small 
pledget  of  absorbent  cotton  with  the  solution  and  place  it  over  the 
external  meatus  and  surrounding  vestibule,  and,  allowing  the  labia 
minora  to  close  together  over  it,  hold  it,  if  need  be,  in  place  five  minutes. 
Take  up  into  a  conical-tipped  urethral  syringe  2  to  4  c.c.  of  the  same 


344  DISK. t  >•/•>'  OF   THE    URETHRA    IX    THE   FEMALE 

solution  and  inject  this  slowly  through  the  urethra,  making  sure  that 
none  escapes  from  the  external  meatus  about  the  syringe  tip,  which 
should  occlude  this  orifice.  If  this  solution  is  slowly  injected  it  distends 
the  urethra  and  comes  into  contact  with  its  entire  surface  until  the 
sphincters  relax  and  permit  it  to  enter  the  bladder  after  a  minute  or 
two.  This  usually  gives  satisfactory  anesthesia,  and  is  commonly 
employed. 

A  stick  applicator  wound  for  3  cm.  from  its  tip  with  absorbent  cotton 
and  wet  in  the  anesthetic  solution  may  be  slowly  passed  through  the 
entire  urethra  and  left  in  place  for  three  minutes  to  produce  excellent 
anesthesia,  but  it  has  the  great  disadvantage  of  rubbing  the  surface 
epithelium  so  as  to  produce  slight  abrasions,  especially  at  the  site  of 
inflammatory  lesions,  ulcerations,  polypi,  etc.,  and  may  give  rise  to 
trouble  in  inspection  or  through  persistent  hemorrhage.  It  is  to  be 
avoided,  therefore,  when  the  urethra  is  the  object  of  examination, 
although  often  useful  for  anesthetization  of  the  urethra  for  cystoscopy. 

With  the  insertion  of  the  urethroscopic  tube  points  of  special  sensi- 
tiveness can  be  anesthetized  as  they  are  encountered  by  withdrawing 
the  obturator,  and,  holding  the  instrument  perfectly  steady,  applying 
to  the  mucosa  with  which  the  obturator  was  in  contact  a  swab  wet  with 
the  anesthetic  solution.  It  is  sometimes  necessary  in  this  way  to 
anesthetize  the  margin  of  the  internal  sphincter  and  the  uppermost 
part  of  the  urethra. 

Urethroscopy. — Instruments. — To  observe  the  mucous  membrane 
within  the  urethral  canal  some  form  of  speculum  or  urethroscope  is 
required. 

For  visual  examination  of  the  urethral  mucous  membrane  (urethros- 
copy)  an  instrument  (urethroscope)  is  necessary  which  either  (1)  opens 
and  holds  apart  the  normally  apposed  walls  so  that  they  may  be  illumi- 
nated and  clearly  seen,  or  (2)  one  which  by  a  prism  or  lens  reflects  light 
falling  upon  a  small  part  of  the  wall  and  carries  the  picture  out  to  the 
eye  through  a  system  of  lenses. 

Urethroscopic  instruments  of  many  varieties  have  been  constructed 
and  commended  since  Griinfeld  (1881)  studied  the  urethral  mucosa 
through  a  glass-windowed  tube  reflecting  light  from  a  head  mirror  into 
this  tube.  A  complete  description  of  the  many  which  possess  merit  and 
of  their  use  is  not  here  attempted. 

The  most  simple  has  proved,  after  the  use  of  practically  every  form 
thus  far  presented,  to  be  the  most  serviceable.  My  own  choice  is  the 
straight  tube  with  a  strong  light  thrown  through  it  from  a  small  electric 
bulb,  such  as  the  light-carrier  made  by  H.  H.  Young  for  his  straight 
male  urethroscopic  tube  or  by  light  reflected  from  the  head-mirror. 
Illumination  by  a  small  electric  bulb  carried  into  the  inner  extremity  of 
the  tube  is  useful  especially  when  the  light  is  sheathed  in  a  compartment 
separated  from  the  examining  tube  (Furniss's  female  urethroscope). 
Urethroscopes  which  are  modifications  of  the  cystoscope  with  lens  sys- 
tems require  skilful  manipulation  and  encumbering  paraphernalia 
entirely  unnecessary  for  routine  work  of  simple,  rapid,  painless  and 


EXAMINATION   or    Till-:   rKMM.K    rRETURA  345 

adequate  inspection  but  should  be  available  for  examination  of  the 
vesical  outlet  and  for  special  cases. 

The  Kelly  urethroscope  and  cystoscope  is  a  cylindrical  metal  tube 
provided  with  an  obturator  whose  end  is  smoothly  rounded  and  whose 
ocular  outer  extremity  is  expanded  in  funnel  shape.  It  is  provided 
with  a  grip  or  handle  set  upon  the  funnel  expansion  and  at  an  angle 
suitable  for  easy  manipulation.  Three  or  more  of  these  instruments  of 
different  sizes  (24,  27,  30  Charriere  scale)  should  be  at  hand  for  use  in 
urethrte  of  varied  caliber.  The  most  useful  size  is  the  No.  30  Charriere 
scale  (10  mm.  diameter),  while  in  young  girls  and  small  women  the 
urethra  will  usually  admit  an  instrument  No.  24  Charriere  scale 
(8  mm.  diameter). 

Its  shaft  with  obturator  in  place  is  lubricated  and  introduced  through 
the  urethra  to  the  bladder  and  the  obturator  withdrawn  permitting  the 
escape  of  urine  which  is  collected  in  a  sterile  glass  or  bottle  for  complete 
examination. 

By  means  of  absorbent  cotton  swabs  on  stick  applicators,  a  dozen  or 
more  of  which  should  be  at  hand,  the  urine  in  the  tube  and  bladder  floor 
is  quickly  wiped  away,  and,  throwing  the  light  through  the  tube,  the 
bladder  wall  is  seen  and  the  instrument  is  slowly  withdrawn  until  the 
internal  sphincter  margin  falls  like  a  fringe  or  curtain  over  the  inner 
extremity  of  the  tube  and  closes  down  over  it  like  an  iris  diaphragm  to  a 
pin-point  opening  and  then  to  closure  of  the  bladder  cavity.  If  the 
patient  is  in  the  dorsal  position,  urine  flows  into  the  tube  rapidly,  so 
gentleness  and  patience  in  swabbing  for  a  moment  or  two  is  necessary 
to  obtain  a  clear  view  of  the  margin  of  the  vesical  outlet  to  study  its 
shape  and  color  and  to  observe  abnormalities.  Since  this  is  a  highly 
sensitive  portion,  it  is  often  well  to  insert  a  swab  soaked  in  4  per  cent, 
novocain  or  other  anesthetic,  and  to  hold  it  for  one  minute  so  that  it 
comes  in  contact  with  the  sphincter  margin.  Facility  and  rapidity  at 
this  point  render  this  application  of  anesthetic  necessary  rarely,  and 
only  in  cases  of  highly  sensitive  lesions  or  markedly  excitable 
women. 

When  the  internal  sphincter  has  closed  over  the  end  of  the  tube  the 
outer  portions  of  the  urethra  are  easily  kept  free  of  fluid  by  the  occa- 
sional wiping  with  dry  absorbent  cotton  on  an  applicator,  and,  by 
very  slowly  drawing  the  tube  outward,  little  by  little,  each  and  every 
part  of  the  urethral  wall  comes  into  view  and  its  characteristics  are 
noted. 

Any  area  upon  the  roof,  floor  or  lateral  walls  can  be  inspected  and 
treated  by  tilting  the  tube  so  that  this  part  is  encircled  by  the  inner 
orifice  of  the  tube.  The  shortness  and  mobility  of  the  female  urethra 
make  this  maneuver  even  more  simple  than  in  urethroscopy  in  the 
male. 

The  normal  urethral  mucous  membrane  beyond  the  end  of  the 
urethroscopic  tube  appears  in  the  form  of  a  flattened  funnel  with 
radial  lines  from  the  central  body  extending  outward  to  the  margins 
of  the  examining  tube.  This  appearance  is  only  obtained  when  the 


340  DISEASES  OF   THE   URETHRA    IX    THE   FEMALE 

central  point  (or  the  long  axis)  of  the  lumen  of  the  tube  corresponds 
with  the  same  point  of  the  urethra.  It  is  fundamental  that  beginners 
should  understand  this  and  learn  to  hold  the  tube  straight  in  the  axis 
of  the  urethra  and  withdraw  it  in  the  same  axis  while  inspecting.  To 
study  noteworthy  areas  the  tube  end  is  diverted  toward  them  and  then 
the  proper  direction  of  the  tube  must  be  resumed. 

The  radially  directed  lines  seen  in  the  mucosa  are  sulci  between 
longitudinal  folds  of  the  mucous  membrane.  The  sulci  in  the  normal 
mucosa  number  about  ten.  If,  now,  we  observe  but  three  or  four  such 
sulci  we  realize  that  swelling  has  occured  to  obliterate  many  sulci  and 
large  smooth  rugae  or  folds  represent  the  abnormal  area. 

The  orifices  of  crypts  and  glands  in  the  mucosa  are  found  here  and 
there  in  the  normal  case  often  with  difficulty,  but  when  these  orifices 
are  the  seat  of  an  inflammatory  process  or  the  glands  are  distended  with 
inflammatory  material,  then  they  are  distinctly  visible  by  the  redness  of 
their  margins  contrasting  with  the  surrounding  mucosa  or  a  tiny  fleck  of 
white  or  yellow  material  marks  them  and  a  tumefaction  in  the  mucosa 
presents  itself. 

In  some  cases  a  ridge  or  fold  of  normal  mucous  membrane  is  found 
upon  the  floor  of  the  urethra  running  down  from  the  trigone  of  the 
bladder  (colliculus  cervicalis).  This  ridge  may  be  continuous  through 
the  length  of  the  urethra  or  it  is  lost  about  1  cm.  anterior  to  the 
internal  sphincter.  Often  a  longitudinal  fold  is  to  be  found  upon  the 
floor  just  within  and  extending  out  through  the  external  meatus. 
About  1  cm.  from  the  external  meatus  a  definite  change  in  the  shape  of 
the  canal  takes  place  sometimes  so  that  it  appears  as  a  transverse  slit, 
and  0.5  cm.  within  the  external  meatus  the  canal  becomes  a  vertical 
cleft. 

The  external  urethral  orifice  is  usually  the  narrowest  part  of  the 
canal,  and  while  it  is  not  so  distensible  or  dilatable  as  the  rest  of  the 
tube,  it  is  usually  dilatable  to  a  considerable  degree.  This  is  an  area  of 
marked  sensibility  and  the  vestibule  and  urethral  orifice  may  require 
the  application  of  a  swab  of  novocain  (4  per  cent.)  or  alopin  (5  per  cent.) 
or  cocaine  (5  to  10  per  cent.)  before  a  satisfactory  examination  can 
be  conducted  with  due  consideration  of  the  patient. 

^^hen  a  urethroscope  or  other  instrument  is  to  be  introduced,  in- 
spection usually  suffices  to  decide  upon  the  size  that  will  comfortably 
pass  the  meatus.  The  most  efficient  examination  of  the  entire  urethral 
wall  is  made  with  the  urethroscope  which  separates  the  folds  to  the 
greatest  reasonable  extent  without  causing  pain.  An  instrument  of 
small  size  necessitates  more  searching  into  the  depths  of  sulci  and 
more  turning  of  the  instrument  from  side  to  side  with  greater  discom- 
fort and  a  more  prolonged  observation  even  in  the  most  experienced 
hands.  A  too  small  instrument  usually  gives  rise  to  more  pain  than 
one  which  smoothly  passes  but  fills  the  urethral  tube. 

When  the  meatus  is  found  with  diameter  smaller  than  the  rest  of  the 
urethra  and  dilatation  is  necessary,  this  is  easily  carried  out  by  anesthe- 
tizing with  novocain  or  other  mucous  membrane  anesthetic  on  cotton 


EXAMINATION  OF   THE  FEMALE   URETHRA 


347 


which  is  applied  to  the  vestibular  surface  of  the  meatus  and  inserted 
within  the  orifice.  Then  insert  a  conical  metal  dilator  and  gently 
press  it  into  the  orifice  until  the  requisite  size  has  been  attained.  If 
this  dilatation  is  slowly  carried  out  with  gentleness,  no  tear  or  bleeding 
will  result  in  the  usual  case  but  a  small  tear  of  1  or  2  mm.  will  occasion 
little  or  no  bleeding  and  no  subsequent  pain  or  ill-effect. 

Occasionally  in  multipart  and  the  aged  the  external  meatus  is  larger 
than  the  main  channel,  so  that  care  must  be  exercised  that  no  forcible 
dilatation  within  the  meatus  is  produced  by  the  introduction  of  too 


FIG.  169. — Young's  urethroscope  and  light  carrier. 

large  an  instrument.  If  the  meatus  is  fibrous  and  rigid,  a  small  cut  in 
the  median  line  on  the  floor  may  be  necessary  to  enlarge  it  after  the 
interstitial  injection  of  an  anesthetic  by  means  of  hypodermic  syringe 
and  needle. 

The  best  means  of  determining  the  size  of  the  lumen  of  the  urethra 
is  by  use  of  silk-elastic  bougies-a-boule,.  so  commonly  employed  in  the 
male  urethra  for  the  detection  of  stricture.  By  this  instrument  con- 
strictions or  narrowness  of  caliber  are  appreciated  with  greater  delicacy 
and  its  use  is  attended  with  less  risk  of  traumatism  than  with  any  solid 
instrument. 


348 


y;/,s/-:.iN/-;x  01-  THK 


i\  THE  FEMALE 


Each  type  of  urethroscope  and  each  modification  of  each  type  has  its 
champions.     X<>  attempt  is  made  here  to  fully  set  forth  the  advantages 


FIG.   170. — Buerger's  cysto-urethroscope. 


FIG.   171. — McCarthy's  close  vision  cysto-urethroscope. 


or  unfavorable  features  of  any.     That  the  reader  may  be  able  to  recog- 
nize some  of  the  best  forms,  a  few  are  represented  in  illustrations. 


MALFORMATIONS  OF  THE  FEMALE   URETHRA  349 

The  following  instruments  should  be  at  hand  for  every  urethroscopic 
examination : 

I  rethroscopes  with  obturators. 

Light-carrier  or  head-mirror. 

Lubricant. 

Cotton  swabs  on  stick  applicators — 12  +  . 

Urethral  forceps. 

Platinum  loop. 

Glass  slides  for  microscopic  preparations. 

Evacuator. 

Urethral  probe  or  searcher. 

Conical  dilator  or  set  of  female  sounds,  graduated  sizes. 

Urethral  syringe. 

Anesthetic  solution. 
For  Treatment. 

High-frequency  machine. 

Silver  nitrate  solutions. 

Urethral  curette. 

Urethral  scissors. 


CT 


FIG.   172. — Kelly's  urethrosoope  and  cystoscope. 

MALFORMATIONS  OF  THE  FEMALE  URETHRA. 

Congenital  defects  of  the  urethra  in  the  female  are  rare.  Hypospa- 
dias,  the  commonest  of  these  errors  in  development,  is  by  no  means  so 
common  as  in  the  male. 

Absence. — Absence  of  the  urethra  has  been  observed  rarely.  In  this 
case  the  bladder  has  opened  into  the  vagina,  or  other  marked  develop- 
mental anomalies  have  been  present  at  the  same  time,  such  as  exstrophy 
of  the  bladder  or  patulous  urachus  for  outlet  of  the  urine.  Atresia  of 
the  urethra,  in  which  some  parts  of  the  wall  have  been  formed  without 
a  patent  channel,  has  been  found  in  a  few  cases  when  some  such  anoma- 
lous opening  of  the  urinary  bladder  as  noted  in  association  with  absence 
of  the  urethra  has  been  present  as  an  associated  defect. 


350  DISEASES  OF    THE    URETHRA   IN    THE   FEMALE 

Malposition. — Malposition  of  the  urethra  occurs  occasionally  as  a 
congenital  deformity  when  the  urethra  is  usually  found  in  a  position  to 
one  side  of  the  median  line,  so  that  the  external  orifice  is  not  in  the 
median  line  of  the  vestibule.  Ordinarily  in  this  case  a  second  dimple- 
like  depression  is  present  in  a  corresponding  position  on  the  other  side, 
indicating  a  partial  formation  of  two  urethral  canals  or  the  bifurcation 
of  the  channel.  Associated  with  this  defect  have  been  found  malforma- 
tions of  the  vagina  (double  vagina)  and  uterus. 

Double  Urethra. — Cases  of  double  urethra  (two  urethrse)  have  been 
recorded — one  canal  arising  from  a  congenital  bladder-diverticulum  in 
some  cases.  Bifurcation  or  forking  of  the  urethra,  in  which  case  the 
single  urethral  canal  arises  from  the  bladder  and  divides  into  two  canals, 
with  separate  openings  on  the  vestibule,  is  more  common  than  two  dis- 
crete canals.  Both  of  these  abnormalities  must  be  differentiated  from 
peri-urethral  fistulous  tracts,  which  are  rarely  congenital  and  sometimes 
the  result  of  inflammatory  processes.  In  many  of  these  cases  one 
channel  serves  as  the  urethra  while  the  other  is  accessory  and  non- 
functionating.  The  abnormal  opening  of  one  ureter  upon  the  vestibule 
or  near  the  urethra  must  be  distinguished  from  these  urethral  abnor- 
malities. 

Hypospadias. — Hypospadias  in  the  female  is  a  pathological  rarity, 
for  while  some  degree  of  it  is  found  in  1  out  of  every  400  males,  only 
35  to  40  cases  have  been  reported  in  the  female.  Hypospadias  is  a  de- 
fective development  of  the  external  portion  of  the  inferior  urethral  wall 
by  which  the  external  meatus  appears  as  an  oblique  opening  on  the 
anterior  vaginal  wall.  It  is  to  be  distinguished  from  congenital  urethro- 
vaginal  fistula  in  which  an  opening  in  any  part  of  the  urethral  floor  con- 
nects with  the  vagina,  while  the  urethral  floor  anterior  to  the  fistula  is 
intact.  Usually  a  furrow  of  urethral  mucosa  upon  the  superior  wall  or 
roof  of  the  urethra  can  be  followed  out  to  or  near  the  normal  site  of 
the  external  meatus  on  the  vestibule.  Cases  are  recorded  of  this 
deformity  ranging  from  slight  defect  near  the  external  meatus  to  total 
absence  of  the  lower  wall  of  the  urethra  combined  with  congenital 
vesico vaginal  fistula,  i.  e.,  a  persistent  urogenital  sinus.  Other  defects 
in  development  of  the  vagina  or  vulva  have  been  found  in  association 
with  hypospadias  (large  clitoris,  posterior  displacement  of  vaginal  ou1  - 
let,  vagina  opening  into  urethra,  etc.).  The  malposed  meatus  is  often, 
as  in  man,  markedly  constricted,  producing  the  same  train  of  symptoms 
as  stricture  of  the  urethra,  and  may  lead  to  dilatation  of  the  urethra  and 
laxity  and  loss  of  control  of  the  sphincters.  Infection  of  any  part  of  the 
urinary  tract  above  a  constricted  hypospadiac  meatus  and  all  sequelae 
of  stricture  may  result. 

Symptoms. — The  urine  may  be  voided  naturally  and  no  symptoms  of 
the  presence  of  this  anomaly  be  evident  to  the  subject  if  the  meatus  is 
well  forward  on  the  anterior  vaginal  wall,  but  the  urine  may  flow  into 
the  vagina  if  the  hymen  be  intact,  and  later  dribble  from  the  vaginal 
outlet,  soiling  the  clothes  and  thighs.  In  hypospadias  of  marked  degree, 
when  the  inferior  wall  of  the  urethra  is  deficient  for  the  greater  part  of 


MALFORMATIONS  OF   THE  FEMALE   URETHRA  351 

its  extent,  there  has  usually  been  partial  or  complete  incontinence  of 
urine  because  of  defect  in  the  formation  of  the  sphincters,  so  that  urine 
constantly  bathes  the  vaginal  wall  and  macerates  the  skin  of  the  vulva 
and  thighs.  Such  a  victim  can  only  by  the  most  scrupulous  cleanliness 
avoid  the  all-pervading  odor  of  decomposing  urine.  This  distressing 
condition  impels  the  patient  to  seek  relief,  and  is  often  the  adequate 
basis  for  operative  repair  of  the  defect.  In  some  of  the  cases  of  this 
defect  in  which  a  very  small  vagina  and  the  urethra  had  a  common 
outlet  (the  vaginal),  "coitus  intra-urethram"  had  been  carried  on  for 
years. 

Treatment. — Cases  of  defect  of  the  floor  of  the  anterior  portion  of  the 
urethra  with  sufficiently  patulous  orifice  which  give  rise  to  no  great 
difficulty  except  strict  attention  to  cleanliness  require  no  surgical  inter- 
vention. If  the  orifice  is  constricted  it  may  be  anesthetized  with 
cocaine  or  novocain  and  dilated  to  a  sufficient  extent  or  incised  and  the 
caliber  maintained  by  occasional  dilatation. 

The  reformation  of  the  inferior  wall  by  plastic  operation  may  be 
accomplished  by  one  of  the  methods  described  for  the  treatment  of 
fistula. 

Epispadias. — Epispadias  is  that  deformity  of  the  urethra  character- 
ized by  partial  or  complete  absence  of  its  superior  wall.  In  the  female 
it  is  much  more  rare  than  in  the  male.  Nove-Josserand  and  Cotte4 
collected  a  record  of  all  reported  cases  in  1907. 

Associated  defects  of  the  pelvic  bones  (separation  of  pubic  bones)  of 
the  vulva,  vagina,  and  anterior  abdominal  and  bladder  walls  are  often 
present  with  epispadias.  The  causation  of  this  defect  is  unknown. 

Three  grades  of  epispadias  have  been  recognized  as  follows — 

1.  The  urethra  opens  just  beneath  the  clitoris. 

2.  The  urethra  opens  beneath  the  symphysis  and  above  or  through 
the  divided  clitoris. 

3.  The  urethra  opens  behind  the  symphysis  and  is  associated  with 
separation  of  the  pubic  bones  and  some  degree  of  exstrophy  of  the 
bladder  with  maldevelopment  of  the  internal  sphincter. 

The  symptoms  of  epispadias  relate  to  the  soiling  of  the  pubic  region 
by  the  escape  of  urine  in  this  abnormal  situation.  In  the  extreme 
degree  of  epispadias  there  is  complete  incontinence,  so  that  the  victim 
is  constantly  bathed  in  urine. 

Treatment. — The  simple  defect  of  the  external  extremity  of  the 
superior  wall  just  below  the  clitoris  necessitates  no  surgical  treat- 
ment. 

Cases  of  second  degree  epispadias  (subpubic  epispadias)  with  no 
defect  of  the  internal  sphincter  of  the  bladder  and  its  resulting  inconti- 
nence of  urine  may  demand  cosmetic  procedures  to  conceal  the  disfigur- 
ing features  of  the  deformity.  This  may  often  be  satisfactorily  accom- 
plished by  plastic  operation  to  restore  the  defective  junction  of  the 
labia  majora  and  minora  in  the  median  line  or  to  reform  the  mons 
veneris  and  clitoris.  The  conditions  presented  in  each  case  must 
determine  the  procedure. 


352  DISEASES   OF    THE    I' RET  Hit  A    IX    THE   FEMALE 

Cases  of  second  or  third-degree  epispadias  (subpubic  or  retropubic), 
with  partial  or  complete  incontinence,  present  a  very  difficult  problem 
with  reference  to  the  means  to  restore  or  to  form  a  substitute  for  the 
bladder-sphincter.  No  satisfactory  substitute  for  a  physiological 
sphincter  has  yet  been  devised.  Whenever  possible  the  tissues  of  the 
sphincter  should  be  brought  together  to  surround  a  reformed  urethral 
canal. 

Epispadias  combined  with  exstrophy  of  the  bladder  becomes  a  prob- 
lem of  bladder  surgery  usually  necessitating  elimination  of  the  bladder 
and  urethra  with  deviation  of  the  urine  from  its  normal  course  by  trans- 
plantation of  the  ureters,  nephrostomy,  etc. 


INJURIES  OF  THE  FEMALE  URETHRA. 

The  commonest  injury  to  the  female  urethra  is  that  produced  in 
childbirth  through  compression  of  its  muscular  tissue  between  the 
child's  head  and  the  symphysis  or  between  instruments  (forceps,  etc.) 
and  the  symphysis.  This  injury  usually  is  not  evident  at  the  time  of 
its  production,  and  its  effects  may  not  be  apparent  for  months  or  even 
years.  Retention  of  urine,  necessitating  catheterization  after  child- 
birth and  after  operations  upon  the  uterus,  appears  to  be  due  to  con- 
tusion or  other  injury  to  the  nerve  supply  of  the  sphincters  and  to  the 
vascular,  lymphatic,  and  muscular  structures  of  the  vesical  outlet 
without  visible  or  palpable  lesion. 

It  is  apparent  that  the  severe  pressure,  often  prolonged,  to  which  the 
urethra  is  subjected  may  result  in  a  serious  contusion  or  even  laceration 
of  the  muscular  fibers  and  of  the  mucosa.  The  later  development  of  a 
weakened  area  in  the  wall  may  be  followed  by  dilatation  of  the  canal, 
or  by  the  formation  of  an  area  of  chronic  infiltration  or  even  of  scar 
formation.  The  injury  to  the  circular  muscular  fibers,  to  the  internal 
sphincter  and  to  the  external  voluntary  sphincter  (compressor  urethra) 
may  result  in  weakening  their  normal  contractile  power  with  resulting 
partial  incontinence  so  frequently  observed.  This  injury,  then,  may  be 
reckoned  as  a  common  cause  of  urinary  incontinence  and  of  urethrocele. 

Its  result  is  not  always  to  produce  incontinence,  but  by  the  injury 
to  the  bloodvessels,  lymphatics,  nerves,  and  mucous  membrane  changes 
follow  slowly  which  appear  later  upon  examination  of  the  urethra  as 
abnormal  chronic  congestion,  chronic  edema  or  an  area  of  defectively 
nourished  mucous  membrane  which  does  not  possess  the  normal  resist- 
ance to  infection,  so  that  chronic  ulceration,  abnormal  hyperplasise 
(polypi  and  villous  excrescences),  and  chronic  infection  may  result. 

The  injury  to  nerves,  while  undemonstrable,  may  reasonably  account 
for  the  changes  in  sensibility  (hypersensibility  or  hyposensibility),  or 
abnormalities  in  muscular,  vascular,  or  trophic  control. 

Many  of  the  disturbances  of  the  function  of  urination  and  many  of 
the  lesions  of  the  urethra  must  be  attributed  to  this  common  but  often 
overlooked  cause  of  urethral  injury — puerperal  trauma. 


INJURIES  OF  THE  FEMALE   URETHRA  353 

Blows  upon  the  urethra,  as  in  falling  astride  of  a  board  or  rail, 
have  been  reported,  but  are  rare  because  of  the  well-protected  position 
of  the  urethra  beneath  the  pubic  arch,  covered  by  the  soft  tissues  of  the 
vulva  and  perineal  body.  Transverse  rupture  and  severe  lacerations 
have,  however,  been  observed. 

Fracture  of  the  pelvis  produced  by  falls  and  crushing  accidents  have 
resulted  in  severe  lacerations  of  the  urethra  by  tearing  or  by  puncture 
of  its  wall  by  ends  of  the  fragments  of  fractured  bones. 

The  urethra  is  in  rare  cases  injured  in  coitus.  With  imperforate 
hymen,  coitus  has  been  accomplished  per  urethram  by  the  gradual 
dilatation  of  the  repeated  act  until  a  marked  enlargement  of  its  caliber 
has  been  produced  and  partial  incontinence  has  resulted. 

Examination  of  the  urethra  and  the  bladder  cavity  by  the  finger  in- 
serted into  it  is  an  obsolete  and  unjustifiable  procedure.  The  dilatation 
so  effected  is  beyond  the  limit  of  safety,  and  has  resulted  in  permanent 
injury  and  incontinence  of  urine.  There  are  rare  cases  of  abnormally 
large  urethra,  hypospadias,  fistula,  etc.,  in  which  the  finger  can  be 
introduced  through  the  canal  without  resistance,  and  in  such  cases  this 
means  of  examination  may  be  permissible. 

Fissure  or  the  persistent  unhealed  tear  in  the  mucous  membrane  in 
which  ulceration  or  chronic  inflammation  exists  has  been  caused  by 
forcible,  rapid,  and  too  wide  dilatation  of  the  internal  sphincter  or  of  the 
meatus.  This  injury  is  produced  by  the  introduction  of  the  finger,  by 
too  rapid  dilatation  with  calibrator  or  sounds,  or  through  the  stretching 
necessary  to  extract  a  calculus  from  the  bladder  per  urethram  or  from 
the  lumen  of  the  urethra  itself. 

Operative  injuries  are  produced  by  intentional  or  unintentional  in- 
cisions into  its  wall,  resulting  in  fistula  or  stricture,  or  in  damage  to  the 
sphincters  controlling  micturition.  In  operations  upon  the  anterior 
vaginal  wall,  anterior  colporrhaphy,  cysts,  and  in  vaginal  approach  to 
the  interior  of  the  pelvis,  the  urethra  is  sometimes  damaged  and  the 
resulting  scar  formation  may  compromise  its  caliber. 

Operations  upon  the  urethra  itself  are  to  be  kept  in  mind  as  a  source 
of  injury.  Overzealous  treatment  can  seriously  impair  the  mucous 
membrane  and  give  rise  to  an  irritability  and  hyperesthesia  of  very 
rebellious  character  or  provoke  and  prolong  a  chronic  infection. 
Serious  hemorrhage  difficult  to  control  and  recurrent  may  result 
from  rough  and  rapid  dilatation,  cauterization,  or  incision. 

Catheter-trauma.  —  Catheterization.  —  The  injury  to  the  female 
urethra,  which  is  a  common  and  potent  cause  of  those  troubles  often 
incorrectly  described  or  referred  to  as  postoperative  cystitis  or  bladder 
irritability,  is  that  produced  by  simple  catheterization.  The  bladder  in 
women  is  often  infected  by  the  passage  of  a  catheter.  When  carelessly 
done  this  is  common,  but  even  every  attention  paid  to  the  strictest 
precautions  and  the  most  detailed  aseptic  technic  does  not  rid  catheteri- 
zation of  its  dangers,  although,  of  course,  the  risk  of  infection  is  thus 
minimized. 

The  writer  is  convinced  that  the  commonly  used  glass  catheter  is 

M  u     I — 23 


354  DISEASES  OF   THE    URETHRA    IX   THE   FEMALE 

dangerous  because  of  the  trauma  which  may  easily  be  produced  by  the 
use  of  this  rigid  instrument,  and  such  slight  traumatism  may  be 
followed  by  infection. 

The  soft-rubber  catheter  is  far  preferable,  because,  although  the 
urethral  mucosa  can  easily  be  injured  by  it,  there  is  much  less  likelihood 
of  such  injury  in  its  use.  Furthermore,  for  its  use,  greater  accuracy  in 
introduction  is  necessary,  and  this  is  an  advantage,  since  it  demands  a 
good  view  of  the  external  meatus,  which  offers  the  opportunity  to  expose 
and  cleanse  the  vestibule  and  keep  it  unsoiled  before  inserting  the  instru- 
ment. When  resistance  is  met  it  is  recognized  by  bending  of  the  catheter, 
that  a  point  has  been  reached  where  slow  and  gentle  pressure  is  called 
for — not  the  hasty  push  that  drives  the  instrument  into  the  bladder. 

In  some  hospitals  the  soft-rubber  catheter  has  been  discarded  for  the 
glass  because  the  records  showed  more  infections  with  it  than  with  the 
glass  catheter.  This  can  be  explained  to  my  mind  because  the  rubber 
catheter  is  the  more  dangerous  when  improperly  employed  without 
good  light,  full  exposure  of  the  part,  and  complete  asepsis.  The  surface 
of  the  rubber  catheter  holds  dirt  and  infectious  matter  after  touching 
the  vagina  or  vulva  more  readily  than  the  smooth  glass,  and  it  carries 
this  infectious  contamination  into  the  urethra  better  than  does  the 
glass.  If,  however,  the  surgeon  or  nurse  inserts  the  tip  of  the  clean 
rubber  catheter  accurately  into  the  meatus,  allowing  no  extraneous 
contact  with  any  part  of  the  catheter,  and  slowly,  with  gentleness, 
guides  it  through  the  urethra,  less  traumatism  will  be  caused  by  it  than 
by  the  glass  catheter,  and  infection  of  the  urethra  and  bladder  will 
rarely  follow. 

Wliile  cystitis  may  follow  catheterization  the  writer  is  convinced  that 
the  much  more  common  injury  or  ill-effect  is  not  cystitis  but  a  urethral 
trauma  and  urethritis.  This  urethral  trauma  or  infection  may  readily 
extend  to  the  bladder,  producing  cystitis;  but  cystitis  is  not  ordi- 
narily a  serious  matter,  and  will  clear  up  promptly  when  the  source  of 
its  infection  (usually  urethral  or  renal  source)  is  remedied.  Cases 
commonly  called  "catheterization  cystitis"  persist  with  perfectly  clear 
urine,  but  with  abnormally  frequent  urination,  discomfort  during  and 
after  urination,  and  the  urethroscopic  evidence  of  chronic  non-purulent 
urethritis,  these  cases  are  usually  promptly  curable  by  urethral 
treatment  only. 

PROLAPSE  OF  THE  FEMALE  URETHRA. 

This  extrusion  of  the  mucous  membrane  through  the  external  meatus 
may  be  partial  (i.  e.,  part  of  the  circumference)  or  complete  when  the 
entire  circumference  pouts  through  the  vestibule.  It  is  due  to  an  ab- 
normal redundancy  of  the  mucosa  and  laxity  of  the  areolar  tissue  be- 
tween mucosa  and  muscular  layers  of  the  wall,  which  accounts  for  its 
appearance  in  little  girls,  or  it  is  due  to  senile  atrophy  and  retraction  of 
the  vagina  and  vulva  in  the  aged.  In  the  aged  the  muscular  and  con- 
nective tissues  of  the  urethra  apparently  share  in  this  atrophy  while 


PROLAPSE  OF  THE  FEMALE   URETHRA  355 

the  mucosa  does  not,  for  the  muscular  walls  appear  to  be  shorter, 
narrower  and  more  fibrous  and  the  mucosa  more  redundant  than 
normal. 

While  the  condition  is  most  common  in  children  and  in  the  aged,  it  is 
occasionally  observed  between  the  fifteenth  and  fiftieth  years  as  a  result 
of  prolonged  labor,  or  of  conditions  which  induce  repeated  straining 
in  urination  for  a  long  time  (vesical  calculus,  urethritis,  urethral 
calculus,  polyp,  etc.,  prolonged  paroxysms  of  coughing,  etc.). 

In  children  the  condition  has  been  brought  on  by  constipation, 
whooping-cough,  vesical  calculus  and  vulvovaginitis. 

Prolapse  may  be  sudden  in  onset  or  of  slow  development.  In  the 
aged  the  development  is  usually  very  gradual. 

Complete  prolapse  of  the  entire  circumference  is  more  common  than 
the  partial.  Partial  prolapse  appears  as  a  pedunculated  tumor,  pro- 
truding from  the  meatus,  whose  base  is  attached  to  some  part  of  the 
wall  within  the  canal. 

The  lesion  appears  on  examination  to  be  a  tumor  at  the  meatus,  red 
like  the  normal  mucosa  when  recent  or  blue  when  congested ;  later  it 
may  be  fissured,  ulcerated  or  necrotic.  It  is  exquisitely  tender,  and 
bleeds  when  touched.  The  meatus  is  displaced  when  the  bulging  is 
greater  in  one  part  than  in  others  but  is  usually  easy  to  find  with  a 
catheter  or  probe.  The  mucosa  presents  in  recent  cases  the  character- 
istic appearance  of  the  urethra  and  is  continuous  with  the  mucous  mem- 
brane covering  the  vestibule  at  the  meatus  and  with  the  urethral 
mucosa  \vithin  the  canal.  These  points  are  important  in  distinguishing 
this  condition  from  prolapse  of  the  bladder  mucosa  through  the  urethral 
canal  or  the  protrusion  of  a  prolapse  of  the  ureteral  mucosa  through 
this  channel.  Caruncle,  polyp,  hemorrhoidal  condition  of  veins  of  the 
urethra  and  very  marked  edema  or  inflammatory  swelling  must  be 
carefully  differentiated.  Urethroscopic  examination  will  give  positive 
information  regarding  the  origin  of  the  lesion,  the  site  of  its  base,  the 
relation  to  the  urethral  wall  and  the  condition  of  the  wall  above  the 
tumor. 

The  subjective  symptoms  usually  complained  of  are  the  presence  of  a 
tender  and  readily  bleeding  area  at  the  external  meatus,  a  sense  of 
burning  pain  during  urination  with  the  feeling  that  there  is  some  foreign 
substance  in  the  canal  and  a  desire  to  expel  it  by  urination. 

Treatment. — Prolapse  of  acute  onset  has  been  observed  to  retract 
without  treatment  and  give  no  further  sign  of  its  presence.  Prolapse 
has  also  been  relieved  without  recurrence  by  manual  reduction  through 
pressure  with  the  fingers  to  replace  the  extruded  mucosa. 

Stockel  advises,  in  young  children,  the  treatment  employed  years  ago 
by  Fritsch,  which  consists  in  passing  a  silk  catheter  to  the  bladder, 
passing  a  sling  of  strong  silk  ligature  over  the  prolapse  close  to  the 
external  meatus  and  tying  this  down  upon  the  circumference  of  the  silk 
catheter.  He  says  that  the  protruded  tissue  becomes  desiccated  and  falls 
off,  so  that  the  catheter  may  be  removed  in  three  days,  complete  healing 
without  serious  infection  follows  rapidly  and  no  general  anesthetic  has 


356  DISEASES  OF   THE   URETHRA   IX   THE  FEMALE 

been  necessary.  In  children  as  well  as  adults  and  the  aged  the  total 
excision  of  the  redundant  portion  and  suture  of  the  margin  of  the 
mucosa  by  interrupted  fine  catgut  sutures  around  the  meatus  is 
preferable. 

Retraction  of  the  mucosa  within  the  canal  during  resection  is  pre- 
vented by  grasping  its  edge  with  forceps  as  it  is  divided  or  by  placing 
sutures  before  severing  it. 

Israel  recommended  cutting  radial  lines  into  the  prolapse  with  the 
cautery  knife.  This  as  well  as  astringent  and  caustic  applications  may 
have  served  in  certain  cases  but  excision  and  suture  is  the  best  pro- 
cedure. A  partial  prolapse  in  aged  women  has  been  treated  success- 
fully by  deep  radial  cauterization  with  the  high-frequency  spark,  but 
this  treatment  is  prolonged  and  attended  with  bleeding  and  necrosis 
which  for  a  time  presents  an  unfavorable  condition.  It  is  not  to  be 
recommended,  although  it  may  accomplish  the  desired  result. 

Under  local  anesthesia  combined  with  interstitial  injection  of  a  weak 
solution  of  the  anesthetic  the  operation  of  excision  can  be  done  in  short 
order. 

CALCULUS  OF  THE  FEMALE  URETHRA. 

Urethral  calculus  in  the  female  is  rare  as  compared  with  this  con- 
dition in  the  male.  Like  prostatic  calculus  in  the  male,  calculi  may 
originate7  in  the  tubular  glands  of  the  female  urethra,  leading  to  the 
formation  of  a  pocket  about  them.  Calcareous  deposit  may  take  place 
in  a  pouch  or  diverticulum  connected  with  the  lumen  of  the  urethra  by 
a  small  or  large  orifice.  Most  calculi  found  in  the  urethra,  however, 
are  of  renal  and  vesical  origin  and  have  been  arrested  in  the  canal  in 
the  course  of  their  descent.  Vesical  calculi  sometimes  present  pro- 
longations into  the  urethra.  Foreign  bodies  inserted  into  the  urethra 
(hairpins,  parts  of  darning  needle,  etc.)  have  been  caught  in  the  canal 
and  served  as  a  nucleus  for  the  deposit  of  urinary  salts. 

Since  the  external  meatus  is  usually  narrower  than  the  rest  of  the 
channel  a  calculus  is  commonly  found  by  inspection,  palpation  or 
instrumental  examination  at  this  point. 

Usually  inflammation  is  set  up  in  the  tissues  in  contact  with  a 
calculus  producing  a  purulent  urethral  discharge  and  pyuria. 

Symptoms. — Calculus  may  lie  in  a  sacculation  connected  with  the 
urethra  or  in  the  canal  close  to  the  external  meatus  without  causing 
noteworthy  symptoms. 

A  calculus  or  any  foreign  body  in  the  urethra  creates  greater  or 
less  disturbance  of  normal  urination — painful  and  abnormally  frequent 
urination  with  a  constant  desire  to  urinate  and  with  a  discharge  of 
mucus  and  pus  from  the  canal  and  perhaps  pus  and  blood  in  the  urine. 

Diagnosis. — If  a  calculus  is  not  visible  at  the  urethral  outlet,  its 
presence  can  usually  be  determined  by  palpation  of  the  urethra  through 
the  vaginal  wall  when  an  abnormal,  tender,  hard  mass  suggests  its 
presence.  With  a  finger  in  the  vagina,  a  metal  or  glass  catheter  or  other 
instrument  may  be  easily  brought  into  contact  with  it  in  the  urethra. 


NEOPLASMS  OF   THE  FEMALE   URETHRA  357 

Calculus  in  a  diverticulum  having  a  small  communicating  opening 
into  the  urethra  may  not  give  the  grating  characteristic  of  contact 
between  calculus  and  the  instrument,  but  the  examiner  is  able  to 
determine  the  position  of  the  dense  mass  felt  through  the  vaginal  wall 
when  the  urethral  instrument  is  inserted  as  a  guide. 

If  a  calculus  is  firmly  held  by  the  urethra  itself  or  by  means  of 
the  finger,  a  urethroscope  may  be  inserted  to  view  it  and  to  aid  in 
its  removal. 

X-ray  examination  will  show  the  presence  of  most  calculi  in  the 
urethra  but  the  necessity  for  this  means  for  diagnosis  rarely  arises. 

Treatment. — When  a  calculus  is  suspected  by  the  examiner,  he  should 
make  sure  that  it  does  not  escape  him  by  being  pressed  or  pushed  back 
into  the  bladder.  This  is  done  by  pressure  upon  the  canal  behind  the 
calculus,  closing  that  avenue  of  escape  and  holding  it  while  an  instru- 
ment is  being  passed  or  the  meatus  dilated. 

If  the  external  meatus  is -narrow,  it  may  be  useful  to  dilate  or  incise 
it  under  local  anesthesia.  By  simple  pressure  from  behind  some  calculi 
and  foreign  bodies  may  be  extruded  which  cannot  be  passed  naturally. 

Calculi  may  be  grasped  and  delivered  by  urethral  forceps,  by  a 
curette  or  bent  probe  or  sling  of  wire  which  has  been  used  to  reach 
behind  a  calculus  and  pull  it  forward. 

Calculi  have  been  removed  from  the  urethra  with  the  aid  of  a  large 
urethroscopic  tube  through  which  one  could  see  and  accurately  grasp 
in  forceps  a  calculus  which  defied  removal  without  the  aid  of  the 
tube. 

Calculus  material  in  a  pouch  or  diverticulum  calls  for  treatment 
of  the  diverticulum  primarily  for  such  a  pouch  will  soon  be  refilled 
with  deposit  if  the  pocket  is  left  after  removal  of  its  contents.  (See 
Treatment  of  Diverticulum.) 

Calculus  may  be  intentionally  pushed  backward  into  the  bladder 
where  it  may  be  crushed  by  a  lithotrite  and  its  debris  washed  out  or  it 
may  be  grasped  by  suitable  forceps  inserted  into  the  bladder  under 
the  guidance  of  cystoscopic  observation  and  so  delivered  through  the 
cystoscope  or  through  the  urethra. 

The  urethral  portion  of  a  vesical  calculus  is  to  be  removed  with  the 
vesical  calculus  by  litholopaxy  or  by  operation  upon  the  bladder. 

After  calculus  has  been  removed  from  the  urethra  an  examination  of 
the  bladder  by  means  of  the  cystoscope  should  be  made  for  the  discovery 
of  other  calculi  lying  ready  to  follow  the  first  and  in  the  majority  of 
cases  a  complete  examination  of  the  entire  urinary  tract  (kidneys, 
ureters  and  bladder)  by  the  means  elsewhere  described  for  the  detec- 
tion of  calculus  is  indicated. 

NEOPLASMS  OF  THE  FEMALE  URETHRA. 

The  neoplastic  structures  originating  in  the  tissues  of  the  urethra 
commonly  observed  are  those  confined  to  the  mucous  membrane  and 
its  bloodvessels  and  usually  benign  in  character,  namely,  papilloma, 


358  DISEASES  OF   THE    URETHRA   IX    THE   FEMALE 

polyp,  cyst,  and  angioma.  Other  benign  tumors  arise  from  the  con- 
nective tissue  (fibroma)  or  muscular  tissue  (myoma)  or  from  both 
(fibromyoma),  but  these  are  comparatively  rare. 

Malignant  tumors  primary  in  the  tissues  of  the  urethra  are  very  rare 
but  of  great  significance  because  of  the  gravity  of  the  condition,  the 
importance  of  early  recognition  of  their  nature  and  the  necessity  for 
prompt  and  radical  removal.  The  malignant  neoplasm  most  commonly 
found  is  carcinoma  originating  in  the  mucous  membrane.  Sarcoma  is 
very  rare. 

Caruncle. — The  frequently  observed  raspberry-like  tumor  at  or  just 
within  the  external  meatus  in  women  is  known  by  the  name  caruncle. 
This  term  does  not  distinguish  a  particular  type  of  tumor,  histologically 
considered,  from  others  of  the  same  gross  appearance  found  in  this 
situation.  This  tumor  is  found  at  all  ages  but  is  most  common  after 
thirty  years  of  age. 

Pathology. — Clinically,  every  small  raspberry-like  tumor  about  the 
external  meatus  is  called  a  caruncle  unless  it  reveals  growth,  invasion 
of  underlying  tissue  or  ulceration  when  cancer  should  be  suspected. 
Cancerous  tissue  may  exist  in  such  a  tumor  at  the  external  meatus  of 
a  woman,  without  growth,  extension  or  ulceration.  Only  upon  his- 
tological  examination  of  the  excised  tissue  can  the  benign  and  can- 
cerous conditions  be  differentiated.  Young,  of  Boston,  has  made  a 
careful  study  of  19  tumors  removed  under  the  clinical  diagnosis  of 
caruncle  at  the  Massachusetts  General  Hospital  during  the  last 
twenty  years.  He  found  5  of  them  to  contain  tissue  of  definite 
carcinomatous  characteristics.  This  is  a  surprisingly  large  proportion 
of  malignancy  in  neoplasms  of  the  urethra,  for  the  opinion  prevails 
that  primary  carcinoma  of  the  urethra,  and  vestibule  is  exceedingly 
rare. 

Neuberger,3  in  a  pathological  study  of  caruncle,  described  three 
varieties:  (1)  granuloma  (not  a  neoplasm  but  a  raspberry-like  tumor 
found  about  the  external  meatus  of  women  due  to  chronic  inflamma- 
tion); (2)  papillary  angioma;  (3)  telangiectatic,  non-papillary  mucous 
polyp.  Caruncle  may  be  said  to  be  any  tumor  found  at  the  external 
meatus  of  the  female  consisting  of  vascular  polypoid,  papillary  or 
granular  tissue. 

It  is  convenient  to  group  these  tumors  under  such  a  term,  for  neo- 
plasms of  every  variety  found  at  this  point  give  rise  to  about  the  same 
symptoms  and  require  the  same  radical  treatment.  All  have  the 
vicious  tendency  to  recur;  all  are  highly  vascular,  are  usually  sensitive, 
bleed  upon  being  disturbed  by  touch  or  as  a  result  of  dilatation  and 
contraction  of  the  canal  in  urination;  all  produce  a  sense  of  burning 
during  urination;  all  increase  in  size,  either  slowly  or  rapidly;  all  should 
be  regarded  as  potentially  malignant. 

Symptoms. — Caruncle  may  lead  to  such  distress  through  pain,  pain- 
ful and  frequent  urination,  hemorrhage,  etc.,  that  the  patient  may 
become  bed-ridden  and  loses  flesh  and  strength.  Neurasthenia  or 
melancholia  may  supervene.  Caruncle  may  exist  without  giving  rise 


NEOPLASMS  OF   THE  FEMALE   URETHRA  359 

to  subjective  symptoms  of  any  kind.  Young  reports  35  per  cent, 
symptomless. 

Treatment. — The  thorough  excision  of  caruncular  tumors  has  been 
the  accepted  treatment,  and  promises  certain  success.  Care  must  be 
exercised  in  the  excision  and  closure  of  the  wound  to  leave  cicatrices 
which  will  not  later  constrict  the  urethra  or  meatus. 

Complete  wide  excision  of  caruncle  is  for  so  small  a  tumor  often  a 
troublesome,  bloody,  and  perhaps  unnecessarily  destructive  attack  upon 
the  urethral  orifice. 

Angioma,  papilloma,  polyp,  granuloma,  and  small  tumors  present- 
ing the  mixed  characters  of  these  neoplasms  found  in  other  parts 
of  the  body  have  been  as  successfully  destroyed  by  the  Oudin  high- 
frequency  current  as  by  excision  with  the  knife.  This  form  of 
electric  cauterization  has  been  extensively  used  in  the  destruction  of 
caruncle,  and  is  our  most  satisfactory  means  of  treatment. 

By  excision  the  specimen  may  be  obtained  for  pathological  study  and 
the  nature  of  the  growth  determined,  whereas  unless  a  part  of  the  tumor 
with  its  base  is  excised  beforehand,  the  destruction  of  the  tumor  by 
cauterization  (Oudin,  cautery,  galvanocautery,  etc.),  as  well  as  .r-ray  or 
radium  treatment,  eliminates  the  possibility  of  histological  examination. 

Oudin  Spark;  Method  of  Application. — After  thorough  anesthetiza- 
tion of  the  mucous  surface  by  the  application  of  cotton  wet  with  novo- 
cain  or  cocaine,  and  the  interstitial  injection  of  the  same  anesthetic 
beneath  the  tumor  through  a  hypodermic  needle,  the  wire  (electrode) 
is  inserted  into  the  little  mass  and  the  current  turned  on  for  15  to  30 
seconds  at  a  time.  The  application  is  made  at  three  or  four  points 
in  the  tumor.  Two  or  three  applications  of  this  treatment  usually 
suffice. 

Cautery;  Method  of  Application. — For  the  use  of  the  actual  cautery 
general  anesthesia  is  necessary.  The  flat,  thin  cautery  blade  is  best 
and  should  be  used  to  sear  furrows  deep  into  the  base  of  the  tumor 
from  each  side.  The  furrows  should  meet  in  the  median  line  of  the 
urethral  floor  above  the  tumor  and  extend  downward  and  inward  to 
meet  beneath  its  base,  cutting  out  a  half-cone-shaped  piece  of  tissue 
which  includes  the  caruncle.  The  application  of  the  dull  red  cautery 
to  the  surface  of  the  tumor  itself  often  effects  its  complete  destruction, 
but  healing  is  sluggish  and  much  pain  may  ensue. 

Galvanocautery;  Method  of  Application. — With  local  and  interstitial 
anesthesia,  or  with  general  anesthesia,  the  galvanocautery  needle  is 
inserted  into  the  base  of  the  mass  at  several  points  for  about  one-half 
minute  each.  Healing  takes  place  by  granulation  after  necrosis  of  the 
tumor. 

Cauterization  by  means  of  chemicals  (nitric  acid,  trichloracetic  acid, 
etc.),  while  efficiently  destructive  of  the  tumor  in  some  instances, 
presents  disadvantages  which  have  led  to  the  abandonment  of  this 
method  in  favor  of  electric  or  thermal  cauterization  or  operation. 

Fibrous  and  smooth-muscle  tumors  (fibroma,  myoma,  and  fibro- 
myoma)  develop  rarely  in  the  tissues  of  the  urethral  wall  but  appear  as 


360  DISEASES  OF  THE   URETHRA  IX  THE  FEMALE 

protrusions  usually  upon  the  anterior  vaginal  wall,  where  they  can  be 
felt  especially  when  a  solid  instrument  has  been  passed  into  the  urethral 
canal.  Such  a  neoplasm  may  constrict  the  lumen  of  the  urethra  and 
give  rise  to  symptoms  like  those  of  stricture.  It  may  grow  to  such  a 
size  as  to  protrude  from  the  vaginal  outlet  and  interfere  with  coitus. 
The  overlying  mucosa  of  the  urethra  may  present  chronic  congestion 
and  edema  with  or  without  infection  or  ulceration. 

Very  small  fibromata  or  myomata  may  call  for  no  treatment.  Large 
tumors  or  those  giving  rise  to  symptoms  should  be  dissected  out  through 
an  incision  of  the  anterior  vaginal  wall  without  opening,  if  possible,  the 
mucous  canal  of  the  urethra. 

Cysts. — Cysts  of  the  urethral  mucous  membrane  of  minute  size  are 
frequently  observed  in  urethroscopic  examinations.  Many  of  these  are 
innocent  tumors  calling  for  no  interference.  Some,  however,  occasion 
symptoms  of  irritation  like  that  of  a  foreign  body  or  of  partial  occlusion 
of  the  channel,  and  under  these  circumstances  they  must  be  destroyed. 
Cysts  are  usually  destroyed  by  thorough  cauterization  with  the  high- 
frequency  spark  (Oudin)  after  the  application  by  swab  of  a  strong  local 
anesthetic  through  a  urethroscope. 

Clipping  them  off  at  the  base  with  urethral  scissors  sometimes 
succeeds,  but  is  likely  to  be  followed  by  recurrence  because  the  amputa- 
tion is  not  complete,  and  troublesome  bleeding  may  follow.  Simple 
puncture  or  splitting  \vith  a  small  knife  is  in  some  instances  adequate. 

Papilloma.  Polyp. — Hypertrophied  projections  from  the  surface  of 
the  mucosa  in  the  form  of  papilloma  or  polyp  are  very  commonly 
observed  in  all  parts  of  the  urethra,  but  are  especially  to  be  found  about 
the  internal  meatus  on  the  margin  of  or  just  outside  the  internal 
sphincter.  These  growths  are  also  frequently  found  near  the  external 
meatus.  They  may  attain  such  size  or  be  in  such  number  as  to  choke 
the  lumen,  giving  rise  to  the  same  symptoms  as  stricture. 

Etiology. — Their  etiology  is  obscure.  In  some,  but  by  no  means 
in  the  majority  of  cases,  a  history  of  a  preceding  urethritis  is  obtained 
or  the  evidence  of  chronic  urethritis  is  revealed  by  urethroscopic  exami- 
nation. In  many  of  the  cases  personally  observed  there  has  been  found 
a  mild  chronic  inflammation  in  the  mucosa  about  them,  but  whether 
this  is  to  be  regarded  as  the  cause  of  the  hypertrophic  growth  or  the 
growth  has  induced  the  irritation  which  has  led  to  inflammation  of 
the  tissue,  has  been  impossible  to  determine. 

These  outgrowths,  even  though  very  small,  occupy  an  important 
place  in  diseases  of  the  female  urethra,  for  they  give  rise  to  exceedingly 
distressing  symptoms  and  are  often  difficult  to  detect. 

Symptoms. — Those  developing  at  the  internal  sphincter  especially 
produce  aggravated  symptoms  such  as  vesical  tenesmus,  painful, 
difficult  and  very  frequent  urination,  hematuria,  often  marked.  They 
may  escape  the  experienced  examiner  who  employs  both  cystoscope 
and  urethroscope  to  find  them. 

One  or  many  of  these  papillary  growths  may  be  present  and  give  no 
symptoms  such  as  detailed  above.  When,  however,  one  or  more  of 


361 

them  is  grasped  by  the  internal  sphincter,  the  most  intense  irrita- 
bility is  aroused  and  bleeding  may  be  quite  profuse.  The  blood  may 
escape  into  the  bladder  or  into  the  urethra  or  both.  Terminal 
hematuria  (i.  e.,  blood  in  the  last  portion  or  the  last  drops  of  urine 
passed)  is  common.  Such  symptoms  may  disappear  after  a  few 
moments  or  hours  or  they  may  be  persistent  for  weeks  or  months. 
A  notable  symptom  usually  is  the  exquisite  sensitiveness  of  that  part 
of  the  urethra  in  which  the  little  villus  is  found,  so  that  the  passage  of  a 
catheter  or  other  instrument  calls  forth  a  cry  or  start  as  this  area  is 
touched,  and  in  many  cases  no  cystoscopic  or  urethroscopic  examina- 
tion can  be  carried  out  without  generous  application  of  cocaine  to  this 
part.  Patients  are  seen  with  whom  general  anesthesia  (gas  and 
oxygen)  and  complete  relaxation  (ether)  is  required  to  accomplish 
the  examination  properly. 

These  little  tumors  do  not  stand  up  for  inspection  as  they  are  de- 
picted in  illustrations,  but  lie  flat  against  the  wall,  often  concealed  in  a 
furrow  or  fold  of  the  mucous  membrane,  so  that  diligent  search  with  the 
cystoscope  or  urethroscope  is  necessary. 

For  those  at  the  vesical  outlet  the  most  satisfactory  means  of  dis- 
covery consists  in  the  use  of  a  close-vision  cystoscope  (Buerger's 
cysto-urethroscope  or  McCarthy's  close-vision  cystoscope  or  similar 
instrument)  with  the  light  and  lens  on  the  margin  between  bladder 
and  urethra,  wrhile  fluid  is  injected  through  the  instrument  into  the 
bladder.  By  revolving  the  instrument,  examining  all  about  the 
sphincter's  margin  \vhile  the  fluid  washes  through  the  instrument 
into  the  urethra,  the  little  villi  are  spread  out  and  fall  back  toward 
the  bladder  and  come  into  view.  In  some  cases  of  obscure  hematuria 
this  plan  has  revealed  a  little  papillary  shred  of  mucosa  pouring  out  its 
blood. 

The  straight  urethroscopic  tube  (Kelly)  will  serve  to  discover  many 
of  these  tumors  and  through  it  they  are  accessible  to  treatment,  but  in 
many  cases  its  use  fails  to  bring  them  into  view  at  the  sphincteric  margin. 

They  can  sometimes  be  well  shown  by  means  of  instruments  which 
employ  air  distention.  The  ordinary  examining  cystoscope  often  shows 
the  projection  of  these  tumors  into  the  bladder.  The  same  excrescences 
are  found  about  the  bladder  surface  of  the  vesical  outlet  and  may  form 
a  fringe  all  about  its  circumference.  They  do  not  always  give  rise  to 
symptoms  or  call  for  treatment.  \\7hen  they  do  fall  into  the  urethra 
from  the  bladder,  or  arise  in  the  urethra,  they  are  likely  to  be  real 
trouble-makers.  Destruction  of  them  is  demanded. 

In  the  urethral  canal. itself  these  papillary  outgrowths  are  found  by 
the  urethroscope  only  and  here  the  straight  tube  must  be  used  to 
stretch  out  and  illuminate  all  parts  of  the  wall  especially  where  deep 
folds  are  seen.  A  full-sized  tube  stretches  the  wall  so  that  during  slow 
withdrawal  any  projection  from  the  wall  falls  into  full  view  over  the 
inner  open  extremity  where  it  may  be  moved  about  by  a  probe  or  ap- 
plicator, examined  in  different  aspects  and  subjected  to  treatment. 
Sometimes  many  of  these  papillomata  are  to  be  found  in  the  urethra. 


362  DISEASES  OF   THE    t'RETHRA   IX   THE   FEMALE 

When  one  or  more  project  from  the  external  meatus  they  are  readily 
found  on  lifting  aside  the  labia  minora. 

These  tumors  are  delicate  wisps  of  tissue  often  but  they  may  contain 
some  connective  tissue  and  possess  considerable  body.  Their  bases 
may  hold  firmly  to  the  surrounding  mucosa,  as  attempts  to  remove 
them  by  avulsion  proves  through  producing  quite  a  tear  running  out 
from  the  base.  They  carry  a  single-looped  bloodvessel  or  are  highly 
vascular  with  many  vessels  large  in  proportion  to  the  size  of  the  growth. 
They  may  recur  after  removal  particularly  when  the  base  is  not  treated 
by  caustic  or  cautery. 

Treatment. — Rarely  the  simplest  form  of  treatment,  such  as  the  appli- 
cation of  a  weak  solution  of  silver  nitrate  (instillation)  or  crushing  by 
forceps  or  amputation  with  scissors,  will  completely  cure  the  patient. 
Incomplete  destruction  of  the  whole  growth,  however,  is  prone  to  lead 
to  recurrence  in  a  short  time. 

The  best  means  at  our  disposal  for  the  treatment  of  this  lesion  is  the 
high-frequency  spark  (Oudin  current).  The  wire  electrode  is  passed 
into  the  base  of  the  growth  and  the  current  is  passed  into  it  for  a 
few  flashes  or  for  fifteen  seconds,  and  the  growth  destroyed  with  small 
likelihood  of  recurrence. 

Amputation  of  the  tumor  at  its  base  by  means  of  little  urethroscopic 
scissors  with  the  application  of  the  silver  nitrate  stick  or  cautery  to  the 
base  is  effectual,  but  after  cutting  the  tissue,  blood  often  obscures  the 
base  and  interferes  with  the  application  and  effectiveness  of  the  silver 
nitrate. 

The  use  of  the  silver  nitrate  stick  or  strong  solution  applied  to  these 
papillary  growths  will  not  infrequently  effect  their  removal.  Several 
applications  are  often  necessary.  This  is  painful  and  by  no  means  so 
certain  as  cauterization  by  the  Oudin  spark. 

Cauterization  with  electric  or  other  (actual)  cautery  is  equally  as 
effective  as  the  Oudin  spark  but  it  is  not  so  completely  controlled;  its 
effect  is  deeper  and  less  defined. 

Malignant  Neoplasms  of  the  Female  Urethra. — Cancer  of  the  urethra 
is  very  uncommon,  although  Young,  of  Boston,  in  a  recent  communica- 
tion reports  that  many  of  the  small  tumors,  clinically  considered 
caruncle,  which  had  been  removed  and  preserved  at  the  Massachusetts 
General  Hospital  Laboratory  presented  definite  evidence  of  malignant 
growth  to  be  classified  only  as  cancer. 

Primary  carcinoma  of  the  urethra  arising  from  its  mucous  membrane 
itself,  apart  from  the  view  presented  by  Young  (and  referred  to  under 
the  subject  of  Caruncle),  is  throughout  the  literature  very  rare; 
probably  not  more  than  25  to  30  critically  studied  cases  have  been 
recorded. 

Carcinomatous  involvement  of  the  urethra  by  the  extension  of  a 
tumor  from  neighboring  tissues  has  been  reported  in  numerous  cases. 
Carcinoma  which  originates  in  the  para-urethral  ducts,  in  peri-urethral 
tissues  in  the  vestibule,  labia,  clitoris,  vagina  or  bladder  may  make  its 
wav  into  the  urethral  tissues. 


\EOri.A.<.M*  Or   THE  FEMALE   URETHRA 

Sarcoma  is  still  more  of  a  curiosity  than  carcinoma  in  connection  with 
the  urethra. 

Since  these  forms  of  neoplasm  may  he  found  in,  or  connected  with, 
the  urethra,  it  behooves  the  examiner  to  be  on  his  guard  for  their 
recognition  and  for  early  thorough  eradication  of  them  when 
found. 

Any  rapidly  progressing  neoplastic  tissue  or  tumor  which  tends  to 
destroy,  through  ulceration,  the  neighboring  tissue,  which  gives  ri>e  to 
pain,  great  tenderness  and  to  recurrent  hemorrhage  (while  it  may  be 
called  a  caruncle)  should  be  under  suspicion,  as  a  malignant  growth  and 
at  least  a  part  should  be  removed  with  a  section  of  its  base  for  critical 
pathological  study  and  diagnosis  of  its  nature.  Wide  excision  of  the 
entire  tumor  as  soon  as  malignant  characteristics  are  recognized  is  the 
safer  course  whatever  the  subsequent  report  upon  its  histology  may 
prove. 

We  have  as  yet  had  insufficient  time  since  the  introduction  of  the 
Roentgen  rays,  radium  and  the  high-frequency  spark  into  therapeutics 
to  draw  hard-and-fast  lines  in  the  critical  judgment  of  the  final 
effectiveness  of  these  means  in  the  treatment  of  cancer  and  sarcoma. 
Yet  in  the  light  of  our  present  knowledge  and  the  experience  gained 
through  the  treatment  of  small  superficial  skin  cancer,  .r-ray  cancer, 
vesical  neoplasms,  rodent  ulcer,  cancer  of  the  lip,  eye,  etc.,  we  can  under 
unusual  circumstances  commend  these  means  for  the  destruction  of  very 
small  malignant  neoplasms.  These  agents  present  advantages  in  that 
the  tissue  is  not  squeezed  or  handled;  already  invaded  lymphatics  and 
,s  are  not  traumatized  or  cut  across,  as  with  the  knife,  leaving  in- 
visible remnants  in  the  freshened  medium  of  healthy  tissue  for  further 
propagation;  the  resulting  scar  is  smaller  and  complete  destruction 
with  proper  technic  is  attainable  in  some  cases.  The  disadvantages  of 
radium. the  Ivoentgen  raysand  even  of  the  high-frequency  spark  are  that 
the  *'  dosage"  has  not  been  determined,  stimulation  instead  of  retarda- 
tion or  destruction  may  be  the  startling  effect,  and  defining  the  action 
to  the  neoplastic  tissue  is  not  possible. 

Every  malignant  neoplasm  removable  by  excision  should  not  be 
tampered  with  by  these  uncertain  agents.  AN  ide  and  thorough  excision 
of  malignant  neoplasms  in  or  connected  with  the  urethra  offers  the 
greatest  security  for  eradication. 

Large  or  inaccessible  growths  must  be  excised  by  circumscribing 
incision  carried  out  in  normal  tissue  and,  under  the  conditions  found  in 
each  case,  as  much  of  the  natural  channel  preserved  as  possible  with 
immediate  or  secondary  plastic  repair.  The  meatus  should  be  left  as  a 
broad,  deep  opening.  The  vaginal  and  urethral  mucous  linings  should 
be  sutured  in  apposition  where  the  vaginal  portion  of  the  urethra  has 
been  amputated.  The  internal  sphincter  should  be  left  intact  if 
possible.  Vesicovaginal  or  suprapubic  drainage  should  be  provided 
during  the  healing  process  in  many  cases  to  prevent  infection  and 
sloughing  after  urethral  suture. 

When  the  entire  urethra  must  be  sacrificed  the  problem  becomes 


364  DISEASES  OF  THE   URETHRA   IX  THE  FEMALE 

one  of  bladder  surgery  with  permanent  suprapubic  drainage,  vesico- 
vaginal  fistula,  transplantation  of  the  ureters,  nephrostomy,  or  other 
provision  for  urinary  outflow. 


STRICTURE  OF  THE  FEMALE  URETHRA. 

The  female  urethral  mucous  membrane  presents  a  lining  layer  com- 
posed of  squamous  epithelium.  Columnar  epithelium  is  present  in  the 
relatively  few  ducts  and  glands  and  it  is  analogous  anatomically  to 
the  membranous  urethra  in  the  male.  Stricture  of  the  membranous 
urethra  in  the  male  is  exceedingly  rare  because  of  the  resistance  to 
infection  offered  by  squamous  epithelium  and  the  absence  of  glandular 
structures  in  or  continuous  with  its  mucosa;  and  so  it  is  in  the  female 
urethra. 

Gonorrheal  ulceration  of  the  female  urethra,  the  forerunner  of  strict- 
ure, has  not  been  observed  and  Stockel6  states  that  "  deeply  penetrating 
ulcerations  of  the  mucous  membrane  with  veritable  loss  of  substance 
which  cicatrize  to  form  stricture  do  not  occur  in  gonorrhea  of  women 
which  has  been  properly  treated  or  not  treated  at  all."  and  he  considers 
such  ulcerations  due,  when  found  during  or  aftei  gonorrhea,  to  improper 
treatment  with  caustics. 

The  causes  of  stricture  in  the  female  are  peri-urethral  abscess,  often 
gonorrheal  in  origin,  injury  of  the  urethra  in  childbirth  by  the  child's 
head  or  by  obstetrical  instruments,  other  injuries  of  the  urethra  which 
are  followed  by  the  formation  of  a  cicatrix,  and  healed  ulcerations  of 
tuberculous  or  syphilitic  nature. 

Constrictions  of  the  urethral  lumen  due  to  a  cicatrix  in  the  under- 
lying vaginal  wall,  to  abscess  or  tumor  in  the  urethra  or  neighboring 
tissues  are  not  considered  here.  Stricture  is  an  acquired  narrowing  of 
the  lumen  of  the  canal  through  the  formation  and  contraction  of  a 
cicatrix  which  results  from  healing  of  a  laceration,  a  rupture  or  a  de- 
structive, ulcerative  process  extending  through  the  mucous  membrane 
of  the  urethra  into  its  submucosa.  This  cicatricial  tissue  is  found  at 
one  point  of  the  circumference,  in  a  segment  or  occupying  the  entire 
circumference  (annular),  and  it  may  extend  to  greater  or  less  extent 
along  the  canal  in  a  longitudinal  direction.  Stricture  of  the  female 
urethra  is  usually  single,  although  multiple  strictures  may  be  found. 

Constriction  of  the  lumen  and  firm  fibrous  infiltration  of  the  entire 
urethra  is  occasionally  observed  in  the  aged.  Its  etiology  is  obscure. 

Symptoms. — Stricture  may  present  no  subjective  symptoms  for  a 
long  period  but  may  be  discovered  upon  the  occasion  of  some  necessary 
instrumentation  of  the  urethra  by  the  surgeon  or  nurse  (catheterization, 
cystoscopy,  etc.). 

The  subjective  symptoms  develop  gradually  and  may  be  present  for 
months  or  even  years  before  the  patient  calls  them  to  the  attention  of 
the  surgeon. 

The  column  of  urine  expelled  through  the  canal  becomes  gradually 


STRICTURE  OF  THE  FEMALE   URETHRA  365 

smaller,  requiring  a  longer  time  for  evacuation  of  the  bladder  and  call- 
ing forth  contraction  of  the  abdominal  muscles  during  inspiration  to 
increase  infra-abdominal  pressure  to  aid  in  expelling  the  urine.  Drib- 
bling after  the  act  of  micturition  has  been  completed  is  common  as  well 
as  interruption  of  the  flow  during  the  act. 

Infection  in  the  mucosa  of  the  urethra  behind  the  stricture  extending 
into  the  bladder  (cystitis)  with  pyuria  are  inevitable  late  results. 

Kolischer  has  called  attention  to  ulceration  of  the  mucous  membrane 
behind  the  stricture,  dilatation  of  this  part  of  the  canal,  congestion  and 
edema  of  the  region  of  the  internal  sphincter,  inflammation  of  the 
bladder  wall  especially  about  the  vesical  outlet  and  trigone  and  hyper- 
trophy of  the  bladder  musculature  with  increased  trabeculation. 

Diagnosis. — The  history  of  one  or  more  of  the  causative  factors:  of 
difficulty  in  urination  of  gradual  development,  of  straining  during  the 
act,  of  interruption  of  the  flow  and  of  the  annoying  after-dribbling  lead 
to  an  examination.  A  stricture  in  the  female  may  be  impassable  with 
any  instrument — impermeable  stricture. 

The  urethroscope  will  demonstrate  the  smooth  cicatricial  tissue  and 
its  pale  color  and  the  coarctation  of  lumen.  It  may  be  possible  to  find 
the  channel  through  the  stricture  by  searching  for  it  with  urethroscope 
and  probe  or  filiform.  This  examination  should  always  be  resorted  to 
before  concluding  that  the  urethra  is  impermeable  to  instruments  and 
applying  the  treatment  demanded  by  the  condition. 

Treatment. — Gradual  dilatation  by  solid  instruments  of  larger  and 
larger  size  until  the  normal  caliber  is  reached  and  maintained  is  the 
best  plan  when  feasible. 

All  undue  traumatism  and  pain  should  be  avoided  through  gentleness, 
very  slow  progress  and  the  use  of  local  anesthetics.  Dilatation  such  as 
to  produce  bleeding  should  be  guarded  against  in  this  treatment. 

The  time  required  in  treatment  for  the  restoration  to  normal  caliber 
and  maintenance  of  this  dilatation  varies  greatly  but  no  patient  should 
be  considered  cured  who  has  been  under  observation  for  less  than  two 
years,  and  a  longer  time  may  be  requisite. 

Internal  Urethrotomy. — This  procedure  is  indicated  in  cases  which 
resist  gradual  dilatation,  so  that  progress  is  not  observed  or  is  very  slow, 
in  cases  which  require  immediate  relief  because  of  the  infection  in  the 
urethra  or  bladder  behind  it,  when  catheterization  must  be  facilitated 
or  cystoscopic  examination  is  demanded,  and  when  the  patient  refuses 
to  undergo  the  prolonged  but  preferable  gradual  dilatation. 

Xo  case  in  which  internal  urethrotomy  is  done  escapes  the  necessity 
for  gradual  dilatation.  The  passage  of  solid  instruments  should  always 
succeed  any  operative  procedure  to  assure  the  patency  of  the  canal. 
After  internal  urethrotomy,  which  provides  an  immediate  enlargement 
of  the  caliber,  the  recontraction  may  be  rapid  unless  the  lumen  is 
maintained  by  the  repeated  passage  of  solid  instruments. 

Internal  urethrotomy  in  the  female  is  carried  out  in  the  same  way  as 
in  the  male.  A  filiform  is  passed  through  the  stricture  to  which  a 
straight  shaft  of  a  Maisonneuve  urethrotome  is  attached.  When 


366  DISEASES  OF   THE    URETHRA   IN   THE   FEMALE 

this  has  been  passed  through  the  stricture,  the  knife  of  proper  size  is 
passed  through  its  groove,  cutting  the  stricture  upon  the  floor  and 
later  upon  the  roof  (upper  wall) .  The  canal  should  be  cut  to  admit  a 
sound  of  28  or  30  French  size. 

Bleeding  may  be  excessive  as  a  result  of  this  procedure,  so  that  a 
cautery  knife  operated  through  an  urethroscopic  tube  is  preferred  by 
many. 

External  Ureihroiowy.- — In  the  female  this  should  consist  in  complete 
exposure  of  the  stricture  by  incision  through  the  anterior  vaginal  wall, 
excision  of  the  fibrous  tissue  followed  by  end-to-end  suture  of  the 
proximal  and  distal  ends  of  the  tube.  Longitudinal  incision  with  ex- 
cision of  the  fibrous  tissue  in  V-shape,  leaving  intact  the  mucosa  on  the 
roof  of  the  canal,  and  then  lateral  suture  of  the  longitudinal  incision  (as 
in  simple  pyloroplasty)  is  a  satisfactory  method. 

External  urethrotomy  should  always  be  accompanied  by  drainage  of 
the  bladder  by  a  small  rubber  tube  or  catheter  passing  through  a  punc- 
ture or  buttonhole  opening  into  the  bladder  floor  through  the  anterior 
vaginal  wall. 

This  drainage  should  be  maintained  for  about  ten  days  to  assure 
healing  of  the  sutured  urethra  before  the  urethra  is  permitted  to 
resume  its  function. 

DIVERTICULUM  OF  THE  FEMALE  URETHRA.— URETHROCELE. 

Diverticulum  or  urethrocele  is  a  pouch  formed  by  dilatation  of  a 
circumscribed  portion  of  the  inferior  wall  of  the  urethra. 

Its  cause  is  ascribed  to  an  injury  of  this  wall  in  childbirth  or  to  the 
destruction  of  the  sustaining  muscular  structures  of  its  wall  by  an 
inflammatory  process  or  by  a  foreign  body  such  as  calculus. 

It  occurs  most  commonly  in  women  who  have  borne  several  children 
and  in  whom  repeated  traumatisms  to  the  vaginal  wall  and  the  sub- 
jacent musculature  of  the  urethra  have  contused  these  tissues..  Less 
common  are  the  cases  due  to  weakening  of  the  wall  from  peri-urethral 
inflammation. 

A  pocket  beneath  the  urethra  formed  by  the  rupture  of  an  asbcess 
into  this  canal  is  simply  a  chronic  abscess  cavity  and  is  to  be  dis- 
tinguished from  true  urethrocele  which  forms  by  bulging  of  the  mucous 
membrane  downward  like  an  acquired  hernial  sac  into  a  weak  spot  in  its 
outer  wall.  The  condition  has  not  been  found  attributable  to  con- 
genital maldevelopment. 

Such  a  pouch  in  a  multipara  may  exist  and  gradually  increase  in  size 
without  being  recognized  for  a  long  period  if  no  infection  of  its  mucous 
lining  occurs  and  urinary  salts  are  not  deposited  in  the  cavity.  Pouches 
connecting  with  the  urethra  which  are  the  result  of  abscess  formation 
usually  persist  as  chronic  abscess  cavities  and  are  especially  prone  to 
hold  a  calcareous  deposit  of  urine  sediment. 

Those  reported  have  varied  in  size  but  have  commonly  been  found  as 
tumefactions  presenting  upon  the  anterior  vaginal  wall  1  or  2  cm.  in 


DIVERTICULUM  OF  FEMALE   URETHRA— URETHROCELE     367 

diameter.  If  the  connection  between  the  diverticulum  and  the  urethra 
is  large,  pressure  upon  its  vaginal  aspect  gives  the  sense  of  a  lax-walled 
cyst  and  its  contents,  expressed  into  the  urethra,  appear  at  the  external 
meatus.  If,  on  the  other  hand,  the  urethral  opening  is  small  or  occluded 
by  calcareous  material,  the  tumor  feels  tense  or  hard. 

An  instrument  (catheter,  small  sound,  or  probe)  may  be  inserted 
along  the  floor  of  the  urethra  into  the  sacculation  and  felt  therein  by  the 
finger  in  the  vagina.  By  examining  the  urethral  floor  with  the  urethro- 
scope  its  opening  into  the  urethra  and  sometimes  the  wall  of  the  cavity 
can  be  explored. 

Cysts  of  the  vaginal  wall  never  communicate  with  the  urethra. 

Calculus  retained  in  the  urethra  tends  to  form  a  bulging  dilatation 
of  the  wall  or  pocket  with  ulceration  of  the  mucosa. 

Cystocele  is  more  voluminous  and  not  a  circumscribed  tumor  on  the 
vaginal  wall  but  a  protrusion  carrying  the  vaginal  wall  with  it. 

Symptoms. — Painful  and  abnormally  frequent  urination,  pyuria, 
hematuria  in  some  cases,  a  tender  area  on  the  anterior  vaginal  wall, 
and  a  urethral  purulent  discharge  are  the  evidences  of  the  condition. 
The  patient  may  report  relief  gained  through  pressure  upon  the  tender 
area  in  the  vagina  which  empties  the  sac. 

The  examiner  by  inspecting  the  anterior  vaginal  wall  and  palpating 
the  tender  tumor  found  there  expresses  its  contents  which  flow  out  of 
the  external  meatus.  He  may  feel  through  the  urethro vaginal  septum 
an  instrument  passed  per  urethram  into  the  sac.  Urethroscopy  reveals 
the  abnormal  extent  of  the  floor  of  the  urethra  or  gives  a  view  of  the 
interior  of  the  pouch  through  a  narrow  opening  into  which  a  probe 
passes. 

Treatment. — Infection  of  the  lining  membrane  of  diverticulum  is  the 
rule,  so  that  healing  after  removal  and  suture  is  problematic.  The  pos- 
sibility of  a  resulting  urethrovaginal  fistula  and  its  subsequent  treat- 
ment must  be  kept  in  mind. 

The  ideal  method  of  treatment  of  urethrocele  is  the  total  excision  of 
the  entire  sac  through  a  vaginal  incision  under  local  and  interstitial  or 
general  anesthesia.  With  a  sound  or  silver  catheter  in  the  urethra  an 
incision  is  made  through  the  vaginal  wall  into  the  sac  of  the  divertic- 
ulum, bisecting  it.  Each  half  is  then  dissected  out  and  the  mucous 
membrane  of  the  urethra  cut  through  along  the  margins  of  the  divertic- 
ulum. This  wound  may  be  closed  by  interrupted  sutures  from  side  to 
side,  passing  through  all  tissues  of  the  bed  of  the  sac  from  the  vaginal 
mucosa  to  the  submucosa  of  the  urethra. 

The  excision  of  an  elliptical  area  of  the  vaginal  wall  and  urethro- 
vaginal septum  shelving  inward  to  the  urethral  canal  may  be  advan- 
tageous in  some  cases. 

Simple  incision  of  the  sac  and  packing  of  the  wound  which  heals  by 
granulation  has  resulted  favorably,  but  often  requires  subsequent 
closure  of  the  fistula.  Incision  and  cauterization  of  the  wall  with  pack- 
ing of  the  wound  has  likewise  succeeded. 


368  DISEASES  OF  THE   URETHRA  IN  THE  FEMALE 

INFLAMMATIONS  OF  THE  FEMALE  URETHKA. 

Infection  of  the  urethra  of  the  female  is  a  condition  the  importance 
and  frequency  of  occurrence  of  which  is  not  sufficiently  impressed 
upon  the  medical  profession  today.  Some  of  the  reasons  for  this 
ignorance  are  to  be  found  in  the  total  absence  of  this  subject  in  under- 
graduate instruction  of  many  of  our  medical  schools  and  the  brief 
and  inadequate  treatment  of  it  in  text-books  as  well  as  the  inex- 
perience of  gynecologists  and  the  medical  profession  as  a  whole  in 
the  careful  study  and  localization  of  lesions  in  the  urinary  tract. 
Many  surgeons  make  frequent  use  of  the  cystoscope  but  rarely,  if 
ever,  employ  the  urethroscope.  Urethroscopy  is  a  more  difficult  pro- 
cedure than  cystoscopy,  demanding  patience,  skill  and  experience,  and 
offers  the  only  means  for  positive  determination  of  most  of  the  lesions 
and  diseases  of  the  urethra. 

Acute,  generalized  purulent  urethritis  in  the  female  is  usually  due  to 
infection  with  the  diplococcus  of  Neisser  (gonococcus) . 

The  diagnosis  of  one  variety  of  acute  urethritis  from  another  depends 
upon  the  demonstration  of  the  bacterial  growth  found  in  the  exudate. 
No  case  of  acute  urethritis  can  be  called  gonorrheal  until  positive  and 
authoritative  demonstration  of  the  gonococcus  has  been  made  in  the 
exudate.  It  is  unscientific  and  morally  wrong  to  fail  to  prove  by  the 
best  bacteriological  evidence  the  character  of  the  germ  present  in  any 
case  of  urethritis.  No  case  of  acute  urethritis  can  be  diagnosticated 
without  bacteriological  study. 

Acute  Simple  (Non-gonococcic)  Urethritis. — Acute  purulent  inflam- 
mation of  the  entire  urethra  due  to  infection  by  other  organisms  than 
the  gonococcus  is  seen  in  prolonged  irritation  of  the  mucosa  by  a 
catheter  retained  through  the  canal  for  drainage  of  the  bladder  and  in 
the  presence  of  other  foreign  bodies  (calculus,  inserted  objects  such  as 
pins,  hairpins,  etc.)  and  after  repeated  traumatisms  or  irritations,  such 
as  the  frequent  use  of  the  catheter  or  overzealous  exploration  and 
treatment. 

Infection  of  the  urethra  by  unclean,  rough,  or  frequently  repeated 
catheterization  is,  in  my  opinion,  very  frequently  the  condition  com- 
monly and  improperly  called  cystitis.  This  does  not  imply  that 
infection  of  the  bladder  (cystitis)  is  uncommon  through  catheter 
infection  but  it  does  imply  that  the  bladder  is  carelessly  regarded  as 
the  seat  of  an  inflammation  or  lesion  which  can  be  shown  to  lie  in  the 
urethra  in  many  cases.  In  many  of  such  cases  the  cystoscope  shows 
normal  conditions  within  the  bladder. 

Acute  inflammation  of  the  urethra  of  non-gonococcic  origin  is  a  con- 
dition of  far  greater  consequence  than  is  usually  accorded  to  it  because 
of  the  rapid  disappearance  of  all  gross  manifestations  of  its  presence 
through  simply  removing  the  cause  of  its  inception  (i.  e.,  removal  of 
foreign  body,  cessation  of  catheterization,  etc.)  and  the  improvement  in 
the  subjective  symptoms.  This  form  of  urethritis  is  regarded  as  of  little 
consequence  just  because  these  signs  and  symptoms  can  so  readily  be 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  369 

explained  and  so  obviously  and  promptly  relieved.  Complete  cure, 
however,  does  not  always  follow  this  manifest  improvement.  In  the 
majority  of  cases,  to  be  sure,  there  is  no  persistence  or  recurrence  of 
symptoms  or  signs  and  a  cure  does  take  place.  In  many  cases,  on  the 
other  hand  (and  every  surgeon  can  recall  such) ,  there  is  a  persistence  of 
the  subjective  complaints  or  a  recurrence  of  them  after  a  time.  The 
urine  then  may  present  no  pathological  elements,  complete  examination 
of  the  urinary  tract  (excepting  the  urethra)  shows  no  renal,  ureteral  or 
vesical  abnormality  and  gynecological  examination  affords  no  evidence 
of  the  cause.  When  an  examination  of  the  urethra  is  made,  the  lesions 
of  chronic  urethritis  are  revealed  and  the  history  of  catheter  infection 
(cystitis?)  is  recalled. 

An  acute  inflammation  of  the  urethra  often  accompanied  with 
involvement  of  the  contiguous  bladder  mucous  membrane  (cysto- 
urethritis,  trigonitis,  cervico-urethritis  so  called)  is  a  common  condition 
the  etiology  of  which  is  obscure.  Among  the  laity  this  is  the  well-recog- 
nized "cold  in  the  bladder."  Exposure  to  cold,  errors  in  diet,  highly 
acid  urine,  alcoholic  excess,  chemical  alteration  of  the  urine  other  than 
abnormal  acidity  due  to  obscure  metabolic  processes  have  all  been  put 
forward  in  explanation  of  the  cause  of  this  condition. 

It  is  well  to  compare  the  condition  with  the  prostatic  infections  of 
obscure  etiology  the  symptoms  of  which,  signs,  course,  duration,  and 
treatment  correspond  with  it. 

In  these  cases  the  colon  bacillus  is  most  commonly  found  in  the 
urine  and  in  pus  obtained  from  the  urethra  and  in  many  cases  a  history 
of  intestinal  disturbance  preceding  or  coincident  with  the  urethral  and 
vesical  symptoms  is  elicited.  Staphylococci  and  streptococci  are  also 
commonly  found  in  this  "simple"  (so-called)  urethritis. 

The  striking  frequency  of  this  urethral  and  vesical  condition  in 
association  with  tonsillitis  and  grippe  has  been  observed  repeatedly. 
Hunner  has  called  attention  to  the  association  of  urethral  and  pharyn- 
geal  conditions  and  the  literature  is  now  voluminous  concerning  the 
relations  between,  or  the  coincidental  abnormalities  of  certain  nasal 
structures  and  the  urethra  and  genital  organs.  In  many  of  these  cases 
symptoms  of  acute  urethral  inflammation  have  been  present. 

Treatment  of  Acute  Non-gonoccocic  Urethritis. — The  removal  of  the 
cause  of  the  inflammation  is  the  chief  feature  in  its  care  and  no  further 
treatment  is  usually  called  for.  The  calculus,  foreign  body  or  catheter 
must  be  removed  from  the  canal.  Catheterization  must  be  stopped  or 
interrupted  for  a  period  when  this  is  possible.  The  technic  of  cathe- 
terization  should  be  carefully  studied  and  errors  corrected. 

Injections  of  argyrol  or  of  some  astringent  such  as  zinc  sulphate  may 
aid  in  hastening  the  subsidence  of  discharge  and  relieve  discomfort,  yet 
these  medicaments  are  usually  unnecessary  unless  the  symptoms  persist 
for  three  or  more  days  after  removal  of  the  cause. 

Prophylactic  treatment  against  the  chronic  urethritis  which  com- 
monly follows  this  simple  acute  urethritis  consists  in  the  early  recog- 
nition of  its  existence,  the  correction  of  the  causative  factors  and  local 
M  u  i — 24 


370  DISEASES  OF  THE   URETHRA   IX   THE  FEMALE 

urethral  treatment  by  means  of  injections  (silver  salts,  zinc  sulphate, 
etc.)  or  through  the  urethroscope  (at  a  later  period,  not  during  the  acute 
stage)  if  the  subjective  or  objective  symptoms  persist. 

Gonococcic  Urethritis. — Gonococcic  urethritis  in  the  female  may 
occasion  such  slight  discomfort  and  be  of  such  short  duration  that 
the  patient  finds  no  occasion  for  recourse  to  the  physician.  She  may 
have  no  discomfort  in  the  urethra  and  no  disturbance  of  urination — no 
subjective  indication.  The  fear  of  detection  even  in  aggravated 
cases  commonly  induces  the  subject  to  conceal  what  evidence  she  has 
discovered  during  the  short  time  that  symptoms  are  present. 

The  very  general  ignorance  of  women,  of  laymen  (and  it  must  be 
admitted  of  physicians  often),  of  the  significance  of  the  symptoms  of 
gonococcic  infection  in  the  female  with  its  insidious,  far-reaching,  and 
calamatous  extension  serves  to  hamper  its  discovery  (often  difficult 
at  best)  and  its  prompt  efficient  treatment.  The  male  practically 
always  knows  that  he  has  acquired  an  infection  while  the  female 
rarely  does. 

While  one  should  carefully  guard  against  the  indictment  of  a  woman 
presenting  a  history  of  urethral  irritability  and  purulent  discharge  or  of 
any  case  with  acute,  subacute  or  chronic  urethritis,  as  of  gonococcic 
origin,  it  may  be  presumed  that  a  girl  or  woman  exposed  to  infection 
of  gonorrhea  with  the  history  of  symptoms  of  urethritis  supervening 
has  had  gonorrheal  urethritis. 

Upon  this  presumption  only  rests  in  many  cases  the  ascribing  of  the 
lesions  of  chronic  urethritis,  suburethral  abscess,  infection  of  para- 
urethral  ducts  without  demonstration  of  the  gonococcus  to  an  original 
gonococcic  infection,  and  with  this  frequently  justified  presumption 
many  cases  are  explained. 

A  woman  may  have,  in  fact,  commonly  does  have,  a  gonococcic  acute 
urethritis  without  realizing  that  she  is  the  victim  of  any  pathological 
process,  wherefore  her  history  is  not  a  factor  comparable  with  the 
search  for  the  pathological  evidence  and  the  bacterium.  She  asserts 
and  believes  that  there  is  "nothing  the  matter  with  her"  and  only  by 
the  most  painstaking  scientific  search,  in  which  asepsis,  perfect  clinical 
and  laboratory  technic,  constant  experience  with  microscope  and  com- 
plete knowledge  of  the  pathology  of  the  disease  plays  each  its  important 
part,  can  the  proof  or  actual  evidence  of  the  nature  of  the  lesion  be 
determined. 

Women  who  present  themselves  to  a  practitioner  for  a  certificate  of 
freedom  from  gonococcic  infection  commonly  are  subjected  to  examina- 
tion by  inspection,  palpation,  and  urinary  examination.  These  means 
are  obviously  inadequate  for  the  discovery  of  nearly  all  cases  except  the 
acute  and  florid.  Most  subsiding  and  chronic  cases  are  not  revealed 
by  such  superficial  means  which,  so  far  as  they  go,  give  normal  signs 
only,  and  the  proof  of  the  disease  is  neglected.  The  failure  of  medical 
examination  of  prostitutes  to  reveal  gonococcic  infectiousness  is  due  to 
the  very  insidious  hiding  of  the  bacterium  in  folds  of  the  rnucosa  or 
beneath  the  epithelium  in  ducts  and  glands. 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  371 

Gonococci  beneath  the  epithelium  actively  promoting  a  small  focus  of 
infection  are  not  discoverable  by  any  means.  It  is  only  when  they 
come  upon  the  surface  or  can  be  brought  to  the  surface  that  they  can  be 
obtained  for  examination.  This  is  one  of  the  reasons  why  a  single 
examination  is  never  adequate  to  give  the  basis  for  the  opinion  that  a 
urethral  mucous  membrane  is  not  infectious.  Several  examinations 
under  the  most  favorable  circumstances  for  finding  the  bacteria  and  the 
most  careful  observation  over  a  long  period  of  time  with  complete 
cooperation  on  the  part  of  the  patient  are  always  necessary  before  the 
opinion  of  non-infectiousness  can  be  given  honestly  and  fairly  in  any 
suspicious  case. 

Lack  of  cooperation  on  the  part  of  the  patient,  who  may  be  very 
fully  informed,  will  nullify  the  value  of  findings  in  markedly  infectious 
cases  of  urethritis.  Simply  by  passing  through  the  urethra  a  small 
part  of  the  urine  just  before  the  examination,  all  evidence  of  the 
presence  of  pus  and  bacteria  can  be  washed  away  and  then  the  urine 
obtained  in  the  examiner's  office  is  normal,  and  of  urethral  secretion 
there  is  none. 

The  patient  is  then  said  to  have  an  "irritable  bladder,"  or  is  said  to 
be  suffering  from  a  "psychic  or  hysterical"  complaint,  without  demon- 
strable lesion,  because  the  urethra  is  not  subjected  to  adequate  and 
competent  scrutiny. 

In  such  cases  the  acute  condition  has  disappeared  from  the 
greater  part  of  the  mucosa,  but  is  persistent  as  an  infection  in  one 
or  more  localized,  perhaps  minute,  areas  where  redness,  swelling  and 
hypersensibility  may  still  be  found  by  means  of  the  urethroscope. 
These  conditions  are  always  obscure  until  exploration  by  the  urethro- 
scope finds  the  lesion. 

Pyuria  without  Urethral  Discharge. — That  acute  purulent  lesions 
persist  in  the  urethra  giving  pyuria  without  discharge  of  pus  from  the 
external  meatus  and  with  normal  bladder  and  normal  kidneys  there  is 
little  question.  An  ulceration  or  persistent  infection  at  the  vesico- 
urethral  junction  or  in  the  urethra  just  outside  the  internal  sphincter 
h'as  been  observed  which  produced  a  surprising  amount  of  purulent 
secretion  that  passed  back  into  the  bladder,  making  the  urine 
densely  turbid.  Secretion  from  this  lesion  does  not  find  its  way 
through  the  external  voluntary  sphincter,  but  like  that  of  purulent 
prostatitis  in  the  male,  does  escape  through  the  internal  sphincter  into 
the  bladder.  Treatment  of  the  bladder  in  such  cases  accomplishes 
nothing  but  is  wasteful  of  time  and  effort,  while  direct  treatment  of  the 
urethral  lesion  is  the  only  means  of  relief. 

Examination  for  Gonococcic  Infection. — The  following  plan  should  be 
followed  when  the  female  urethra  is  to  be  examined  for  the  detection  of 
the  diplococcus  of  Neisser,  and  the  same  principles  apply  for  examina- 
tion of  the  cervix,  glands  of  Bartholin  and  vagina,  all  of  which  are 
usually  examined  at  the  same  time. 

The  patient  must  take  no  douche  or  bath,  and  must  not  wash  the 
vulva  for  twelve  hours  preceding  the  examination.  She  should  not 


372  DISEASES  OF  THE   URETHRA  IN   THE  FEMALE 

void  the  urine  for  at  least  three  hours,  and  it  is  preferable  that  twelve 
hours  elapse  preceding  the  examination.  It  is  often  well  to  instruct 
the  patient  to  come  to  the  examination  early  in  the  morning  without 
voiding  urine  since  retiring  the  night  before. 

Xo  washing  of  the  vulva  by  a  nurse  is  permitted  when  the  patient  is 
prepared  for  examination. 

The  labia  are  separated  and  specimens  of  any  secretion  are  taken  up 
with  a  platinum  loop  or  thoroughly  sterilized  cotton  swabs  and  spread 
upon  glass  slides,  labelled  according  to  the  site  where  secretion  is  found, 
and  cultures  made  at  the  same  time  upon  suitable  media.  Thus  often 
one  set  of  three  to  six  slides  is  labelled  labia  minora ;  another  set,  vesti- 
bule; and  still  others,  external  meatus;  vaginal  orifice;  vagina;  right 
Bartholin;  cervix,  etc.  This,  it  may  readily  be  seen,  promises  labor  for 
the  laboratory,  but  that  is  what  the  laboratory  is  for,  and  the  duty  of 
the  conscientious  examiner  demands  at  least  that  the  work  be  thor- 
oughly done. 

Secretion  obtainable  at  the  external  urethral  orifice  must  be  sepa- 
rately collected  upon  a  set  of  slides  to  differentiate  it  from  that  obtained 
within  the  urethra.  The  urethra  may  be  free  of  infection  while  its 
outlet  is  bathed  in  pus  from  the  vagina  or  from  an  infected  para-urethral 
duct  which  may  open  outside  the  canal. 

The  urethral  meatus  is  then  opened  by  separating  its  margins  with 
the  fingers  and  the  vestibule  and  orifice  are  washed  with  cotton  sponges 
wet  with  salt  solution  and  then  dried  with  sterile  gauze.  The  platinum 
loop  (fired  and  cooled)  or  a  sterile  cotton  swab  on  an  applicator  is  in- 
serted into  the  canal  0.5  cm.  and  withdrawn  and  the  secretion  upon  it 
spread  immediately  upon  slides.  This  may  be  repeated  several  times 
to  obtain  a  sufficient  number  of  specimens  for  careful  search.  It  can  be 
done  painlessly  and  without  trauma. 

No  vaginal  examination  by  means  of  the  finger  or  speculum  should 
be  made  until  these  specimens  from  the  urethral  orifice  and  canal  have 
been  secured. 

Now  the  hairpin  retractor  of  Kelly  or  a  bent  probe  is  inserted  into  the 
urethral  meatus  to  expose  the  orifice  of  one  and  then  the  other  of  Skene's 
ducts  while  pressure  is  made  below  the  floor  of  the  anterior  part  of  the 
urethra  against  the  vestibule  or  upon  the  anterior  wall  of  the  vagina, 
close  to  the  vaginal  outlet,  and  the  appearance  of  secretion  expressed 
from  the  duct  taken  up  and  preserved  on  specially  labelled  slides 
(left,  Skene;  right,  Skene,  etc.). 

The  whole  urethra  is  then  stroked  from  the  bladder  to  the  external 
meatus  (from  behind,  forward)  through  the  anterior  vaginal  wall.  This 
can  be  done  in  infants  often  without  strain  or  rupture  of  the  hymen. 

Several  specimens  of  all  secretion  thus  obtained  must  be  preserved 
upon  labelled  slides  and  cultures  made  at  the  same  time  on  appropriate 
media,  such  as  blood  serum,  etc.,  for  bacteriological  study. 

If  search  is  to  be  made  (as  must  commonly  be  the  case)  in  the  vagina, 
cervix,  vulvovaginal  glands,  etc.,  this  should  now  be  carried  out. 

The  vagina  is  then  cleansed  by  douche  or  by  sponges  on  sponge 


INFLAMMATIONS  OF  THE  FEMALE   CRETHKA  373 

holders  and  mopped  dry  with  gauze  or  cotton,  and  the  vulva  is  washed 
with  salt  solution  and  dried  with  gauze. 

The  patient  is  then  instructed  to  urinate  into  two  sterile  beakers — 
a  small  portion,  or  the  first  gush  of  urine,  in  one,  and  the  remainder  of 
the  bladder  contents  into  the  other.  All  of  the  urine  in  glass  Xo.  1 
should  be  centrifugalized  and  the  sediment  thoroughly  searched  for 
pus  and  for  bacteria,  and  cultures  should  be  made  from  this  sediment 
under  laboratory  precautions. 

The  patient  again  takes  her  place  on  the  table  and  a  critical  examina- 
tion of  the  entire  urethral  mucosa  is  made  with  the  urethroscope, 
through  which  all  adherent  mucus  and  pus  upon  the  walls  is  secured  for 
bacteriological  examination,  and  lesions  are  carefully  noted. 

No  case  of  suspected  gonorrheal  infection  of  the  urethra  has  had  a 
thorough  or  adequate  examination  unless  a  routine  as  complete  as  this 
has  been  followed,  and  no  case  can  be  declared  free  of  gonorrheal  in- 
fection unless  repeated  complete  tests  of  this  sort  are  carried  out  after 
stimulation  of  the  urethra  and  para-urethral  ducts  with  silver  nitrate  or 
other  irritant  directly  applied.  The  doubtful  expedient  of  the  ingestion 
of  alcoholic  beverage  to  irritate  this  part  of  the  urinary  tract  may  aid  in 
promoting  the  appearance  of  discharge,  which  is  to  be  searched  for  the 
offending  organism. 

Acute  Gonococcic  Urethritis. — This  is  an  acute  exudative  inflamma- 
tion of  the  mucous  membrane  involving  the  entire  extent  of  the  canal, 
due  to  the  lodgment  and  growth  upon  and  in  the  mucosa  of  the  gono- 
coccus  or  diplococcus  of  Neisser. 

It  is  acquired  by  adults  almost  exclusively  in  coitus,  although  the 
bacteria  may  be  transferred  through  freshly  soiled  objects,  such  as 
douch-nozzle,  towels,  toilet  seats,  etc.  Infection  except  through  sexual 
contact  is  very  rare  in  adults,  while  the  transference  of  the  bacterium 
from  an  infected  source  to  the  more  delicate  and  more  susceptible  mu- 
cous membrane  of  the  vulva  of  the  infant  or  young  girl  is  common 
through  contaminated  objects,  such  as  clinical  thermometers,  diapers, 
towels,  toilet  seats,  the  hands  of  attendants  and  nurses. 

The  little  girl  who  sleeps  in  bed  with  an  infected  individual  may 
acquire  this  infection  from  secretion  deposited  upon  the  bedclothes  or 
through  handling  by  infection-carrying  hands.  This  source  of  infection 
is  common  among  the  poorer  classes  who  visit  our  free  clinics,  and  is 
not  uncommon  among  all  classes.  In  children  the  urethra  is  readily 
infected,  but  is  rarely  the  site  of  persistent  and  chronic  foci.  Long- 
continued  vulvovaginitis  in  children  is  usually  due  to  chronic  infection 
in  the  cervix  uteri.  Repeated  reinfections  of  the  urethra  from  this 
source  may  occur. 

Acute  gonococcic  urethritis  in  the  female  is  usually  a  short-lived 
process,  lasting  from  three  or  four  days  to  three  weeks  in  untreated 
cases.  The  acute  symptoms  consist  in  itching  or  burning  in  the  ure- 
thra, with  a  scalding  sensation  during  urination,  frequent  desire  for 
micturition,  more  or  less  urethral  discharge  of  pus  containing  gonococci, 
and  occasionally  some  blood  or  terminal  hematuria.  These  symptoms 


374  DISEASES  OF   THE   VRETHRA   IX   THE  FEMALE 

last  for  a  few  days  and  arouse  often  slight  attention  on  the  part  of  the 
victim,  so  that  she  does  not  consult  a  physician.  When  the  pain  is 
great  or  frequent,  imperative  calls  for  urination  with  strangury  arise, 
or  the  discharge  is  florid  and  she  is  unaccustomed  to  vaginal  discharge, 
or  blood  is  observed  at  a  time  apart  from  a  menstrual  period,  any  of 
these  conditions  may  lead  her  to  seek  medical  examination  for  relief. 
It  i-,  however,  to  be  remembered  that  a  woman  will  usually  patiently 
bear  the  above-mentioned  discomforts  in  the  hope  that  they  will  soon 
pass  away,  and  she  commonly  ascribes  them  to  some  indiscretion  in  diet. 
Her  hope  is  often  fulfilled,  and  she  believes  herself  unaffected  by  any 
serious  condition  because  of  the  subsidence  of  all  subjective  symptoms 
after  a  few  days.  On  the  other  hand,  symptoms  may  be  aggravated 
and  prolonged,  and  the  victim  may  immediately  seek  medical  advice. 

On  examination  in  the  acute  case  the  external  meatus  is  dark  red  and 
swollen,  with  discharge  flowing  from  it  or  readily  expressed  by  the 
slightest  pressure.  The  vestibule,  meatus,  and  urethra  per  vaginam 
are  exquisitely  tender  to  touch.  The  secretion  transferred  to  a  micro- 
scopic slide  shows  pus  with  the  characteristic  biscuit-shaped  extra- 
cellular and  intracellular  diplococci,  which  are  negative  to  the  Gram 
stain,  and  cultures  from  this  secretion  grow  the  characteristic  colonies 
of  this  organism  on  suitable  media.  The  orifices  of  Skene's  ducts  may 
stand  out  as  pouting  red  points  when  exposed  just  within  the  meatus. 
Pressure  upon  these  ducts  through  the  vestibule  or  through  the  vagina 
shows  a  drop  of  pus  at  the  orifice,  and  palpation  of  the  urethra  per 
vaginam  gives  pain,  causes  an  increase  of  the  discharge  at  the  meatus, 
and  the  normal  cord-like  feeling  of  the  urethra  above  the  vagina  is 
changed  by  the  soft  thickening  of  its  walls,  due  to  the  inflammatory 
infiltration.  If  gonococci  are  not  found  in  the  secretion  from  the 
urethra,  but  are  present  at  this  time  in  secretion  from  other  parts  of 
the  genital  tract,  this  bacterium  may  reasonably  be  presumed  to  be 
the  exciting  cause  of  the  acute  urethritis  and  subsequent  searches  will 
usually  reveal  them  in  the  urethral  secretion. 

The  examination  of  the  vagina,  vulvo vaginal  glands,  and  cervix  is 
now  usually  proceeded  with  and  the  vagina  cleansed  and  dried  with 
gauze,  and  the  vestibule,  labia,  and  vaginal  outlet  cleansed  by  washing 
and  dried  with  gauze. 

The  patient  passes  urine  into  two  sterile  beakers.  In  the  portion 
voided  first,  shreds,  pus  and  gonococci  are  found.  The  second  beaker 
may  contain  clear  urine  or  it  may  be  cloudy  or  turbid  with  pus.  The 
pus  in  the  second  beaker  may  be  due  to  purulent  inflammation  in  the 
juxtavesical  portion  of  the  urethra  corresponding  with  posterior 
urethritis  in  the  male;  it  may  be  due  to  cysto-urethritis  or  to 
cystitis. 

In  acute  inflammation  of  the  urethra,  when  the  gonococcus  is  readily 
demonstrated  in  the  secretion,  no  urethroscopic  examination  should  be 
attempted.  It  is  painful,  requiring  thorough  anesthesia  with  novocain 
or  cocaine,  and  the  introduction  and  manipulation  of  the  instrument 
produces  traumatisms,  with  trifling  hemorrhages  even  in  the  most  deft 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  375 

hands,  tending  to  give  rise  to  extension  and  aggravation  of  an  already 
grave  inflammatory  process.  No  catheter  or  other  instrument  should 
be  passed  through  an  acutely  inflamed  urethra  unless  imperatively 
necessary. 

If  voluntary  urination  is  interfered  with  by  reason  of  the  pain  and 
swelling  in  the  canal,  the  patient  must  be  instructed  to  attempt  to 
void  urine  while  sitting  in  the  hot  sitz  bath  or  while  hot  applications 
are  made  to  the  vulva  and  pubic  regions,  so  that  catheterization  and 
its  trauma  may  be  prevented. 

During  or  subsequent  .to  the  acute  stage  of  gonorrheal  urethritis  the 
inguinal  lymph  nodes  may  be  found  to  be  enlarged  and  tender  or  even 
to  be  the  seat  of  abscess  formation. 

After  a  few  days  (one  to  ten  days,  but  two  to  four  days  commonly) 
the  subjective  and  objective  symptoms  and  signs  rapidly  disappear. 
Urination  becomes  normal,  urethral  discharge  is  slight,  mucoid,  with 
little  pus,  and  the  redness  and  swelling  of  the  meatus  disappear.  There 
persists,  however,  for  ten  to  fourteen  days  longer  the  evidence  of 
urethritis  in  shreds  in  the  urine,  a  little  more  than  normal  secretion 
from  the  mucosa,  and  pus  is  to  be  found  in  the  shreds  and  in  the 
urethral  secretion  as  well  as  some  gonococci. 

The  orifices  of  Skene's  ducts  will  usually  show  for  a  week  or  two 
as  distinct  red  points,  just  within  the  meatus  on  each  side,  and  from 
them  may  be  expressed  a  tiny  drop  of  pus  in  which  gonococci  may  be 
found  on  careful  search. 

If  the  urethroscope  is  employed  in  this  stage,  red  points  and  infil- 
trated areas  are  to  be  found  along  the  urethra,  and  these  are  most 
numerous  and  most  marked  in  the  parts  of  the  mucosa  which  are  pro- 
vided with  glands,  notably  at  the  upper  extremity  and  near  the  external 
meatus.  These  infected  areas  are  the  lesions  which  persist  as  chronic 
foci  of  inflammation. 

In  this  subsiding  stage  the  woman  may  consider  herself  well  even  if 
she  has  recognized  during  the  florid  stage  that  a  definite  disease  process 
has  been  in  action,  yet  the  secretion  from  the  urethra  is  highly  infectious. 

Now  the  active  process  has  subsided,  and  there  persists  for  a  short 
or  long  time  the  periods  described  as  the  subacute  and  chronic  stages. 

The  subacute  stage  is  merely  a  continuance  of  the  subsiding  acute 
process.  It  is  an  indefinable  period ,  during  which  very  slight  subjective 
and  objective  symptoms  and  signs  remain.  It  may  be  said  to  have  a 
duration  of  from  two  to  five  weeks. 

It  is  well  known  and  has  been  stated  above  that  acute  gonococcic 
urethritis  in  the  female  usually  subsides  in  less  than  ten  days  to  a  sub- 
acute  condition  of  relative  comfort,  as  the  patient  observes,  and  one  in 
which  the  objective  signs  are  scarcely  manifest.  This  subacute  stage 
has  a  duration  of  from  ten  days  to  five  weeks.  Urethritis  persisting 
longer  than  five  weeks  is  to  be  called  chronic. 

The  pathological  condition  has  during  the  first  two  to  ten  days  been 
an  active  acute  exudate  inflammation  of  the  entire  mucous  membrane. 
The  entire  inner  membrane  (epithelium)  is  during  this  stage  swollen, 


376  DISEASES  OF  THE   URETHRA   /.V   THE  FEMALE 

deep  red  in  color,  and  covered  with  yellow  fluid  pus.  The  bloodvessels 
are  dilated,  leukocytes  are  packed  into  the  submucous  and  mucous 
layers  and  escape  upon  the  surface,  which  is  secreting  an  abnormal 
quantity  of  mucus,  and  the  epithelium  is  desquamated  as  individual 
cells  or  in  plaques  or  groups  of  cells.  Minute  hemorrhages  take  place 
into  the  mucosa  and  upon  its  surface.  The  gonococci  are  to  be  found 
in  the  epithelial  cells  and  penetrating  between  cells  in  the  mucous  and 
submucous  layers,  and  within  the  leukocytes. 

Wherever  crypts,  lacunae,  folds,  or  glands  exist  the  inflammatory 
process  extends  into  the  depths,  and  gonococci  penetrate  into  the  lower- 
most recesses  and  out  into  the  surrounding  tissues  about  such  crypts 
and  glands.  Minute  abscesses  are  thus  formed,  which,  bottle-like,  may 
be  shut  off  from  the  canal  through  adhesion  or  occlusion  of  their  outlets, 
to  open  again  as  the  inflammation  surrounding  them  subsides,  with  dis- 
charge of  the  infectious  contents  into  the  main  channel  of  the  urethra, 
giving  rise  to  recrudescence  or  recurrence  of  the  diffuse  inflammation 
throughout  the  canal.  These  pockets  of  infection  in  glands,  crypts, 
and  sulci  are  the  sites  of  long-persisting  lesions,  often  microscopic  in 
size,  but  large  in  their  potency  for  recurrent  or  chronic  infection. 
Some  minute  lesions  may  extend  or  coalesce  to  form  gross  areas  of 
suppuration,  called  suburethral  and  peri-urethral  abscess,  and  perfora- 
tion of  such  a  suppuration  through  the  vaginal  wall  brings  about 
urethrovaginal  fistula.  It  is  to  be  particularly  noted  that  glandular 
structures  are  found  in  the  upper  third  and  in  the  lower  third  of  the 
urethra,  and  that  these  portions  present  the  chronic  lesions  and  are 
the  sites  of  suburethral  abscess. 

Infection  of  the  para-urethral  (Skene's)  ducts  affords  a  nidus  for  long- 
continuing  suppurative  inflammation  or  recurrent  abscess  formation. 
In  glands  and  gland-like  structures  the  gonococcus  finds  its  natural 
habitat,  and  it  is  in  these  structures  that  it  maintains  acute,  subacute, 
and  chronic  inflammation  untouched  by  medicaments  applied  to  the 
lumen  of  the  urethra,  and  undiscovered,  it  may  be,  by  any  of  the  means 
which  we  now  possess  for  searching  it  out. 

Treatment  of  Acute  Gonococcic  Urethritis. — It  may  be  stated,  at  the 
outset,  that  the  proper  care  of  any  woman  infected  by  the  gonococcus 
demands  the  most  painstaking  attention  to  every  detail,  and  treatment 
to  be  effective  must  be  carried  out  in  part  by  a  nurse  and  in  part  by  the 
surgeon.  A  nurse  should  care  for  her  wants  while  she  remains  in  bed, 
apply  compresses,  give  urethral  treatments,  regulate  the  diet,  and  see 
that  water  is  taken.  This  can  be  accomplished  only  among  those  who 
have  command  of  their  time  and  the  means  to  provide  themselves  with 
every  necessity.  In  many  cases  no  such  plan  can  be  carried  out.  The 
patient  may  not,  for  varied  reasons,  take  to  her  bed,  admit  a  nurse  to 
her  home,  and  permit  daily  treatment  by  a  surgeon.  The  feasible 
approach  to  ideal  care  often  consists  in  the  daily  visit  to  the  physician's 
office,  where  treatment  is  administered.  A  daily  renewal  of  the  anti- 
septic tampon  and  irrigation  of  the  urethra  can  be  made.  The  effective- 
ness of  these  means,  however,  is  lost  after  a  few  hours,  so  that  she  is 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  377 

practically  without  treatment  during  the  greater  part  of  each  twenty- 
four  hours. 

Abortive  treatment  is  impracticable  because  of  the  fact  that  the 
appearance  of  symptoms  sufficiently  marked  to  attract  the  patient's 
attention  indicates  a  stage  of  inflammation  when  the  bacteria  have 
penetrated  beneath  the  superficial  epithelium,  so  that  medicaments 
applied  to  the  surface  fail  to  reach  and  kill  them. 

The  vagina,  vulvovaginal  glands,  and  cervix  must  be  protected,  if  not 
already  infected.  If  infection  has  taken  place  in  any  part  of  the  genital 
tract,  appropriate  treatment  must  be  carried  out  at  the  same  time  with 
that  directed  to  the  urethra. 

In  the  very  acute,  florid,  and  fortunately  rare  cases  of  urethritis,  with 
exquisite  pain  and  tenderness,  no  local  treatment  should  be  undertaken 
until  the  aggravated  symptoms  have  subsided;  but  the  protection  of 
the  vagina  and  cervix  may  be  attempted  in  some  cases  by  the  insertion, 
twice  daily,  of  a  tampon  saturated  with  2  per  cent,  protargol  and  the 
repeated  cleansing  of  the  vulva  with  warm  solution  0.5  per  cent,  pro- 
targol or  1  to  2000  potassium  permanganate.  Vaginal  douches  admin- 
istered by  the  patient  herself  present  an  element  of  danger  in  the 
introduction  of  a  nozzle  which  may  carry  contamination  as  it  enters 
the  vagina.  The  application  to  the  vulva  of  clean  hot  compresses, 
frequently  renewed,  offers  the  safest  palliative  measure. 

The  patient  should  remain  in  bed  and  an  opiate  given,  if  necessary, 
to  secure  quiet.  She  should  be  kept  upon  a  fluid  diet,  milk  chiefly,  and 
drink  copiously  (10  to  15  glasses  a  day)  of  water,  preferably  alkaline 
water.  This  course  is  required  for  twro  or  three  days  at  most,  when  the 
pain  usually  subsides. 

In  the  less  aggravated  cases  the  application  of  clean  hot  compresses 
is  beneficial,  while  the  patient  remains  in  bed  for  the  greater  part  of  the 
day  and  limits  exercise  to  the  minimum.  The  compresses  should  be 
available  in  abundance,  and  each  should  be  destroyed  after  once  having 
been  applied,  so  that  the  infectious  secretion  is  removed.  A  compress 
is  removed  when  cold  or  soiled,  and  at  each  micturition. 

A  vaginal  tampon  soaked  in  2  per  cent,  protargol  or  other  antiseptic 
is  to  be  renewed  daily. 

Injection  through  the  urethra  (argyrol,  protargol,  silver  nitrate, 
potassium  permanganate)  into  the  bladder  (with  the  aid  of  novocain 
1  per  cent,  previously  if  need  be)  should  be  used  during  the  active  stage 
four  or  five  times  in  twenty-four  hours.  Sufficient  quantities  (5  iv  to 
vj)  should  be  used  so  that  the  bladder  is  filled  and  stimulated  to  expel 
the  fluid  again  through  the  urethra  in  voluntary  urination.  If  silver 
salts  (argyrol,  protargol,  silver  nitrate)  or  potassium  permanganate 
(1  to  2000)  is  used,  there  is  little  danger  of  infection  of  the  bladder  by 
this  means. 

The  use  of  a  catheter  or  recurrent  irrigating  tube  (Janet)  or  other 
instrument  in  the  inflamed  urethra  is  contra-indicated.  Its  trauma  is 
more  to  be  feared  than  that  of  an  antiseptic  fluid  gently  injected,  which 
enters  the  bladder  and  is  expelled  again  voluntarily. 


378  DISEASES  OF   THE   URETHRA  IN   THE  FEMALE 

Bland,  simple  diet,  consisting  largely  of  milk  and  laxative  food, 
should  be  taken.  Alcohol  and  condiments  must  be  avoided.  The 
bowels  should  be  kept  free  by  some  vegetable  cathartic.  Laxative 
salts  and  aperient  waters  often  are  irritating. 

The  treatment  of  the  subsiding  stage  of  the  acute  gonococcic  ure- 
thritis  consists  in  a  relaxation  of  the  strictness  of  diet  and  quiet,  but  by 
no  means  of  the  local  treatment.  Antiseptic  tampons  should  still  be 
used  daily  to  serve  as  protection  against  infection  of  the  cervix.  In- 
jections of  one  of  the  silver  salts  per  urethram  are  to  be  continued 
daily,  twice  or  three  times  if  possible.  Copious  water  drinking  should 
continue  and  condiments  and  alcohol  must  be  avoided.  Exercise 
should  be  limited. 

The  conclusion  that  a  cure  has  been  obtained  can  only  be  reached 
when  repeated  search  for  the  gonococcus  has  failed  to  re  veal  its  presence, 
when  no  pus  is  found  in  the  urethral  secretion  or  in  voluntarily  voided 
urine,  when  no  sign  of  inflammatory  lesion  is  found  in  the  mucosa 
examined  by  urethroscope  or  about  the  external  meatus,  and  when 
the  gonococcus  complement-fixation  test  of  the  patient's  blood  proves 
negative.  Not  one  or  several  of  these  factors  are  adequate  for  a  clean 
bill  of  health.  All  must  be  clear  in  indication  of  health  before  the 
patient  is  to  be  regarded  as  cured. 

It  is  well  to  be  ultracautious,  and  conservative,  and  to  give  no  assur- 
ance of  cure  until  one  to  three  months  after  an  apparent  cure,  during 
which  period  examinations  of  the  parts  affected  and  searches  for  the 
bacterium  are  to  be  made  at  intervals.  Unsuspected  recrudescence  is 
common. 

Complications  of  Acute  Urethritis. — Acute  urethritis  is  in  practically 
every  case  which  is  due  to  the  gonococcus  accompanied  by  infection  of 
the  para-urethral  glands — Skene's  ducts. 

The  treatment  of  these  infected  ducts  is  best  carried  out  after  the 
acute  urethritis  has  subsided,  and  should  consist  in  the  effort  to  destroy 
the  duct  by  cauterization.  The  injection  of  antiseptics  or  weak  solu- 
tions of  caustics,  so  generally  advised,  is  usually  a  prolonged  treatment 
and  futile  as  a  curative  measure. 

The  duct  can  usually  be  sounded  by  a  fine  probe  or  large  hollow 
needle,  the  point  of  which  has  been  dulled  and  rounded.  The 
wire  electrode  for  high-frequency  spark  cauterization  or  galvano- 
cautery  can  thus  be  used  to  destroy  the  infected  channel,  or  injec- 
tions of  strong  silver  nitrate  solution,  20  per  cent,  to  50  per  cent., 
or  of  95  per  cent,  carbolic  acid  may  be  made  into  the  depths  of 
the  duct  through  a  needle  such  as  used  for  intramuscular  mercurial 
injections. 

Cystitis  or  inflammation  of  the  trigone  or  vesical  outlet  (cervico- 
urethritis)  commonly  complicates  urethritis  in  the  female.  Treatment 
of  the  urethral  inflammation  disregarding  the  bladder  usually  results  in 
speedy  recovery  of  the  bladder  inflammation. 

Topical  applications  to  the  trigone  and  vesical  outlet  may  be  neces- 
sary during  the  subsiding  stage.  Treatment,  however,  which  consists 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  379 

in  injections  through  the  urethra  into  the  bladder  accomplishes  the 
double  purpose. 

Suburethral  abscess  is  a  complication  of  acute  or  chronic  urethritis, 
which  fortunately  rarely  follows.  This  abscess  is  found  below  the 
urethra  in  the  urethrovaginal  septum  by  extension  from  submucous 
glands,  which  are  infected  and  do  not  discharge  their  contents  into  the 
urethra.  The  periglandular  tissues  are  infiltrated  and  inflamed,  or 
several  minute  intraglandular  abscesses  fuse  together  to  form  a  gross 
lesion  the  size  of  a  hazel  nut  or  hickory  nut,  giving  rise  to  great  pain, 
exquisite  sensitiveness,  and  pain  and  difficulty  in  voiding  urine. 

Suburethral  abscess  is  found  beneath  the  anterior  one-third  of  the 
urethra,  in  which  case  the  para-urethral  ducts  are  usually  the  seat  of 
origin  of  infection  or  the  Suburethral  abscess  is  found  below  that  part 
of  the  urethra  nearest  the  bladder  (posterior  one-third)  when  the  origin 
is  in  the  glands  of  the  mucous  membrane  of  this  part.  The  proximity 
to  the  internal  vesical  sphincter  gives  rise  to  great  pain,  constant  desire 
to  void  urine,  strangury,  etc. 

Suburethral  abscesses  tend  to  rupture  into  the  urethral  canal  rather 
than  through  the  denser  tissues  of  the  vesicovaginal  septum  and  the 
vaginal  mucosa,  which  sometimes  does  take  place. 

The  treatment  of  Suburethral  abscess  consists  in  giving  vent  to  it  as 
promptly  as  possible.  This  can  be  accomplished  by  incising  the  over- 
lying vaginal  wall  into  the  abscess  cavity,  but  the  danger  of  urethro- 
vaginal fistula  as  a  consequence  is  great  and  its  repair  may  be  trouble- 
some at  a  later  date.  This  should  be  the  treatment  of  abscess  near  the 
external  meatus.  The  writer  believes  it  to  be  preferable  in  the  case  of 
abscess  near  the  bladder  (posterior  one-third)  to  give  a  general  anesthetic, 
dilate  the  urethra  to  normal  limits  (30  or  31  Charriere  scale)  and,  if  this 
does  not  result  in  discharge  of  the  abscess  into  the  urethra,  to  incise  the 
floor  of  the  urethra  into  the  abscess,  to  give  the  natural  physiological 
drainage  without  opening  the  vaginal  wall.  The  likelihood  of  fistula 
formation  is  less  and  healing  has  been  prompt  and  uneventful  in  one  or 
two  cases  so  treated.  Bleeding  may  be  quite  profuse,  but  is  usually  con- 
trollable by  pressure  per  vaginam.  A  retained  catheter  is  usually  neces- 
sary for  a  day  or  two,  and  opiates  are  required  to  control  the  pain. 

Chronic  Urethritis. — Inflammations  of  the  urethra  which  persist  over 
a  long  period  of  time  are  found  in  the  female  as  in  the  male  almost 
without  exception  in  and  about  glands  of  the  mucous  membrane  or  in 
gland-like  structures.  Chronic  urethritis  is  usually  the  aftermath  of  an 
acute  inflammation  and  the  persistent  lesions  are  confined  to  those 
parts  in  which  glandular  structures  are  found,  namely,  in  the  proximal 
one-third  or  the  distal  one-third  of  this  tube.  While  in  many  cases  it  is 
difficult  to  demonstrate  a  purulent  exudate  in  urethral  discharge,  in 
shreds  in  the  urine  or  in  suppurative  foci  by  means  of  urethroscopic 
examination,  there  is  always  a  suppurative  process  going  on  in  the 
tissue  as  the  basis  of  this  chronic  urethritis.  When  the  gonococcus  has 
been  the  original  invader,  this  organism  may  in  many  cases  persistently 
reside  in  the  depth  of  gland-like  structures  and  maintain  a  low  grade  of 


380  DISEASES  OF   THE   URETHRA   7.V   THE  FEMALE 

suppurative  inflammation.  When  the  gonococcus  is  recoverable  in  the 
urethra!  exudate  the  diagnosis  of  chronic  gonococcic  urethritis  is  made. 
When,  however,  the  gonococcus  is  not  demonstrable  in  the  secretion 
obtainable  from  the  urethra  while  other  organisms  are  present,  the 
organism  found  may  be  either  the  original  invader  or  it  may  be  one 
which  has  replaced  the  gonococcus  in  the  inflammatory  tissue  (second- 
ary infection) . 

The  sequela  of  chronic  inflammation,  such  as  stricture,  "proliferating 
urethritis,"  and  "fibrous  urethritis"  (Legueu)  have  been  considered 
elsewhere. 

Infection  by  the  gonococcus  is  the  most  frequent  cause  of  chronic 
urethritis,  and,  while  authoritative  statistics  upon  its  frequency  are  not 
available,  it  is  recognized  as  a  common  condition.  Many  cases  of 
chronic  urethritis  are  ascribable,  with  reasonable  presumption,  to  a 
previous  transient  acute  urethritis  of  gonococcic  origin. 

Many  cases  of  chronic  urethritis  in  women,  on  the  other  hand,  are  the 
result  of  acute  infection  of  the  glandular  structures  of  the  mucous 
membrane,  especially  in  the  juxtavesical  portion  of  the  canal  produced 
through  traumatism  during  catheterization,  during  childbirth,  and 
through  various  possible  injuries  of  the  urethra,  as  well  as  the  results  of 
those  little-understood  and  often  inexplicable  cases  of  urethral  lesions 
occurring  during  epidemics  of  grippe,  and  as  complications  of  tonsillitis, 
pharyngitis,  nasal  and  dental  lesions.  The  writer  has  seen  cases  of 
urethral  inflammation  with  purulent  exudate  coincidental  with 
suppuration  about  a  tooth  which  disappeared  (were  apparently  cured) 
when  the  dental  lesion  was  removed. 

Pathology. — The  pathological  condition  differs  from  that  found  in 
acute  urethritis  in  the  absence  (usually)  of  inflammation  diffused 
throughout  the  entire  mucous  membrane  of  the  canal,  while  the  glan- 
dular structures  maintain  the  discrete  foci.  There  may  be  but  one 
gland-like  structure  involved,  as  when  one  of  Skene's  ducts  presents  the 
only  focus,  or  multiple  foci  may  be  present,  as  when  many  minute  lesions 
are  found  in  the  upper  or  lower  portion  of  the  canal.  These  lesions  may 
give  rise  to  a  visible  purulent  exudate  which  is  found  at  the  external 
meatus  or  is  readily  brought  to  view  by  pressure  upon  the  canal  in 
such  a  way  as  to  force  it  to  the  meatus.  There  may,  on  the  other  hand, 
be  so  minute  an  amount  of  exudate  that  none  is  visible  even  after 
massage  of  the  urethra,  and  centrifugalization  of  the  first  portion  of 
urine  passed  may  reveal  only  a  few  scattered  leukocytes  by  microscopic 
examination  of  the  sediment. 

Chronic  urethritis  is  observed  in  all  ages,  uncommonly  in  childhood, 
more  frequently  in  young  adults  and  is  most  common  in  those  who  have 
borne  children.  It  is  not  uncommon  in  women  of  advanced  age. 

Symptoms. — The  symptoms  of  chronic  urethritis  are  those  so  often 
erroneously  attributed  to  "cystitis"  and  "irritable  bladder,"  namely, 
discomfort  or  pain,  painful  urination  at  the  bladder  outlet,  abnormally 
frequent  desire  for  urination,  rarely  urethral  discharge,  pus  and  shreds 
in  the  first  portion  of  urine  voided,  pyuria  and  hematuria  in  some  cases. 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  381 

The  symptoms  of  vesical  irritability,  discomfort  at  the  bladder  out- 
let, sense  of  titillation,  pain  on  retention  of  urine,  frequent  or  constant 
desire  to  pass  urine,  are  all  sensory  disturbances  arising  in  the  urethra, 
producing  impulses  to  the  reflex  centres  of  micturition.  When  in- 
hibitory control  of  this  reflex  is  inefficient  to  check  it,  involuntary 
urination  takes  place. 

If  such  injury  as  the  traumatism  to  the  urethral  structures  produced 
in  some  cases  of  childbirth  has  weakened  the  internal  and  especially  the 
external  voluntary  sphincter,  the  irritation  caused  by  the  lesions  of 
chronic  urethritis  may  start  the  reflex  of  micturition,  and  the  damaged 
musculature  of  the  sphincters  fails  to  occlude  the  canal  in  spite  of 
voluntary  efforts,  and  involuntary  micturition  takes  place. 

Changes  in  the  urine  may  be  noticed  by  the  patient  if  marked  pyuria 
or  hematuria  is  manifest.  Marked  pyuria  may  be  due  to  a  chronic 
suppurative  lesion  in  the  urethra,  outside  of  the  bladder,  whose  exudate 
passes  back  through  the  sphincter,  clouding  the  bladder  contents. 
Extension  of  the  urethral  inflammation  through  the  sphincter  to  the 
mucosa  within  the  bladder,  upon  the  trigone  and  about  the  vesical 
outlet  is  common  but  does  not  always  take  place. 

All  cases  presenting  the  above-mentioned  symptoms  should  be  sub- 
jected to  critical  examination  of  the  urethra. 

Diagnosis. — Palpation  of  the  urethra  per  vaginam  will  usually  localize 
areas  of  special  tenderness,  and  rarely  small  nodular  thickenings  or 
larger  infiltrations  can  be  thus  appreciated.  Exudate  can  some- 
times be  expressed  from  the  meatus  by  pressure  upon  the  canal  per 
vaginam  from  the  bladder  outlet  downward  to  the  urethral  orifice. 
This  exudate  is  to  be  examined  carefully  for  morphological  elements 
(pus  particularly)  and  by  search  for  bacteria  in  stained  spreads  as  well 
as  culturally.  The  type  of  bacterium  should  always  be  determined. 

Exposure  of  the  lower  1  cm.  of  the  urethra  about  the  external  meatus 
by  means  of  retractors  will  often  reveal  the  inflammatory  swelling, 
redness,  and  exudate  present  in  this  part. 

The  orifices  of  ducts  which  open  upon  this  mucous  membrane,  are 
often  plainly  visible  to  the  naked  eye,  but  more  clearly  seen  with  a 
magnifying  glass  by  red  areolse  surrounding  them. 

The  lesions  inside  a  narrow  meatus  and  those  located  farther  within 
the  urethra  are  only  discoverable  through  the  urethroscope.  In  fact, 
no  case  of  chronic  urethritis  can  be  diagnosticated  or  efficiently  treated 
without  the  use  of  the  urethroscope. 

By  means  of  the  urethroscope  areas  of  soft  infiltration,  of  dense 
induration,  as  well  as  the  common  multiple  minute  points  of  swelling, 
redness,  and  suppuration  can  be  readily  recognized  and  directly  treated. 
"  Granular  urethritis"  is  the  chronic  inflammation  of  the  mucous  mem- 
brane which  resembles  granulation  tissue  and  is  found  in  isolated  cir- 
cumscribed areas  or  occupying  the  whole  extent  of  the  canal.  The 
gross  appearance  as  seen  by  the  urethroscope  is  the  same  in  the  chronic 
inflammation  due  to  the  gonococcus  and  in  that  due  to  pyogenic  cocci, 
the  colon  bacillus  or  other  organisms.  The  differential  diagnosis 


382  DISEASES  OF   THE    URETHRA   /.V    THE   FEMALE 

between  the  inflammations  produced  by  different  bacteria  is  made 
solely  by  the  demonstration  of  the  bacterium  present. 

Treatment. — The  treatment  of  chronic  urethritis  produced  by  the 
gonococcus  and  by  other  organisms  is  in  general  the  same,  and  consists 
chiefly  in  direct  topical  application  to  each  lesion.  This  can  be  done 
satisfactorily  only  through  the  urethroscope. 

Gonococcic  inflammation  because  of  its  infectiousness  demands 
special  and  stringent  precautions  against  transmission  to  others.  When 
chronic  gonococcic  urethritis  is  present,  all  contaminated  vulvar  pads, 
compresses,  clothing,  etc.,  must  be  destroyed  or  sterilized  and  preserved 
from  contact  with  other  individuals.  Coitus  is  interdicted  and  the 
patient,  nurses,  and  others  concerned  in  the  case  must  be  instructed 
concerning  the  dangers  of  contamination  to  the  eyes  and  other  parts, 
and  the  strictest  cleanliness  observed.  The  dangers  of  infection  of 
children  (male  as  well  as  female)  must  be  particularly  pointed  out. 
The  patient  must  sleep  alone. 

The  direct  treatment  of  the  lesions  discovered  by  the  urethroscope 
aims  to  destroy  each  focus.  If  the  superficial  tissue  (the  mucnsa  of  the 
canal)  presents  evidence  of  inflammation,  each  point  should  be  treated 
by  applying  silver  nitrate  solution  upon  a  small  swab  through  the  ure- 
throscope. Novocain  or  cocaine  anesthesia  may  be  needed  for  each 
examination  and  treatment.  The  strength  of  solution  of  silver  nitrate 
applicable  varies  with  each  case.  Usually  it  is  best  to  begin  with  a 
weak  solution  and  observe  the  result,  but  the  strongest  solution  up  to 
20  per  cent,  or  even  to  the  use  of  the  pure  stick  silver  nitrate  fused  upon 
a  probe  should  be  employed  when  possible.  The  high-frequency  spark 
after  cocainization  is  in  some  cases  very  effective  especially  when 
hypertrophic  tissue  is  found. 

The  result  of  any  treatment  of  the  urethra  is  in  some  cases  surpris- 
ingly painful  after  the  effect  of  the  local  anesthetic  has  been  lost,  so  that 
the  direction  should  be  that  the  patient  keep  as  quiet  as  possible  (in 
bed)  for  three  to  six  hours  after  the  treatment,  and  resort  to  hot  sitz 
baths,  hot  douches  and  hot  applications,  hot-water  bag,  compresses, 
etc.,  as  needed.  Morphin  is  required  in  some  cases. 

Lesions  which  lie  beneath  the  surface  epithelium  must  be  exposed  for 
treatment  and  for  free  drainage  or  destroyed  by  the  high-frequency 
spark.  Localized  indurated  areas  which  harbor  a  chronic  inflammatory 
focus  should  be  incised  with  a  knife,  or  scissors  of  special  form,  through 
the  urethroscope  or  laid  open  by  the  electric  cautery  knife  or  actual 
cautery. 

Para-urethral  ducts  which  persistently  harbor  infection  are  treated  by 
passing  a  small  hollow7  needle  through  the  extent  of  the  duct  and  injecting 
slowly  a  drop  or  two  of  95  per  cent,  carbolic  acid  or  20  per  cent,  silver 
nitrate,  or  by  passing  the  wire  electrode  and  destroying  the  duct  by 
cautery  or  high-frequency  current.  These  means  of  treatment  of 
chronic  infection  of  para-urethral  ducts  are  often  adequate,  but  some 
cases  are  more  promptly  cured  by  incising  the  canal  upon  a  fine  grooved 
director,  to  lay  it  open  upon  the  vaginal  wrall  for  evacuation  of  its  con- 


INFLAMMATIONS  OF  THE  FEMALE   URETHRA  383 

tents  and  direct  treatment  of  the  tissue  involved.  Suburethral  abscess 
is  rarely  the  lesion  maintaining  a  chronic  urethritis. 

Chronic  urethritis  is  by  these  means  curable.  The  treatment  may 
demand  application  to  the  diseased  area  once  in  ten  days  for  a  long 
period  (one  to  six  months).  Four  to  six  treatments  are  almost  always 
required  before  the  patient  experiences  decided  relief  from  the  distress- 
ing subjective  symptoms,  and  still  more  treatments  are  usually  needed 
to  restore  the  pathological  areas  to  normal  appearance. 

An  area  of  urethral  mucous  membrane  (glandular  structures)  which 
has  once  harbored  a  chronic  inflammation  remains  a  part  of  lowered 
resistance,  so  that  a  recurrence  (reinfection)  is  common.  Each  recur- 
rence requires  repetition  of  treatment,  but  recurrences  recognized  and 
treated  at  their  inception  are  usually  readily  controlled.  Cases  of 
chronic  urethritis  complicated  by  incontinence  of  urine  are  common. 

The  cure  of  the  inflammatory  lesion  often  results  in  complete  restora- 
tion of  urinary  control.  When  the  incontinence  is  due  to  damaged 
tissue  of  the  sphincters  or  to  laxity  of  the  urethral  tissues  produced  by 
urethrocele,  cystocele,  or  prolapse  of  the  uterus,  bladder  and  urethro- 
vaginal  tissues,  operative  restoration  to  normal  conditions  must  be 
sought. 

Nervous  diseases  which  affect  the  bladder  and  its  sphincters  must 
always  be  sought  for  in  every  case  presenting  symptoms  of  chronic 
urethritis,  incontinence  or  retention  of  urine,  or  pain  referred  to  the 
urethra. 

Xo  case  presenting  typical  signs  and  symptoms  of  chronic  urethritis 
should  escape  examination  for  those  vesical,  pelvic  and  nervous  condi- 
tions which  produce  similar  symptoms  and  signs. 


BIBLIOGRAPHY. 

1.  Kalisher:  Urogenit.  Musculatur  des  Dammes. 

2.  Luciani's  Human  Physiology,  ii,  461. 

3.  Neuberger:  Berliner  klin.  Wchnschr.,  1894,  No.  20. 

4.  Nove-Josserand  and  Cotte:  Revue  de  Gynecol.  et  Chir.,  1907,  xi,  963. 

5.  Schafer:  Microscopic  Anatomy,  Quain. 

6.  Stockel:  Veit's  Handbuch  der  Gynecol.,  ii,  287. 

7.  Virchow:  Archiv  fur  path.  Anat.,  1853,  v,  403. 


CHAPTER  XI. 
STRICTURE  OF  THE  URETHRA. 

BY  EDWARD  L.  KEYES,  JR.,  M.D. 

URETHRAL  STRICTURE. 

STRICTURE  of  the  urethra  is  an  abnormal  constriction  or  loss  of  dis- 
tensibility  of  that  channel. 

Stricture  occurs  in  the  female  as  well  as  in  the  male  urethra.  In 
either  sex  it  may  be  classed  as  congenital,  inflammatory,  and  traumatic. 

Further  subclassification  mav  be  made  as  follows : 


Stricture  of  the  male  urethra 


Stricture  of  the  female  urethra 


Congenital. 
Traumatic. 
Inflammatory. 

Gonorrheal. 

Tubercular. 

All  others. 


It  is  important  to  specify  how  much  narrowing  or  loss  of  distensi- 
bility  of  the  urethra  constitutes  stricture,  for  whether  the  lesion  be 
congenital  or  acquired,  it  merits  the  name  of  stricture  only  after  it  has 
reached  a  point  of  contraction  at  which  it  is  inevitable  either  that 
symptoms  result  or  that  further  contraction  ensue.  But  the  size  varies 
with  different  types  of  stricture  as  well  as  for  different  urethrse.  It  is 
equally  impossible  to  specify  the  precise  size  to  which  a  stricture  must 
be  dilated  in  order  that  its  tendency  to  recontraction  may  be  controlled. 

Thus  a  congenital  stricture  no  larger  than  20  F.  is  likely  to  give  no 
symptoms  unless  its  possessor  acquire  a  gonorrhea,  which  cannot  be 
cured  until  the  stricture  is  cut. 

On  the  other  hand ,  any  traumatic  scar  surrounding  the  urethra  will 
soon  contract  sufficiently  to  cause  symptoms  to  be  clinically  a 
stricture. 

For  gonorrheal  stricture,  Oberlaender  recognizes  "  hard  infiltrations" 
of  various  degrees  (p.  301),  a  urethroscopic  tube  of  23  F.  size  being  the 
criterion.  Infiltrations  of  the  first  degree  do  not  perceptibly  impede 
the  passage  of  the  urethroscope  and  are  not  lacerated  by  it.  Infiltra- 
tions of  the  second  degree  admit  the  instrument  but  are  abraded  by  it. 
Those  of  the  third  degree  do  not  admit  the  urethroscopic  tube.  We 
may  accept  this  classification  and  recognize  that  infiltrations  of  the 
first  degree  only  remotely  and  rarely  form  the  basis  of  stricture,  while 
those  of  the  second  and  third  degree  may  be  spoken  of  as  true  strictures. 
(384) 


STRICTURE  OF   THE   URETHRA  385 

It  is  to  be  remembered,  however,  that  the  sound  or  bougie  commonly 
employed  for  the  diagnosis  of  stricture  engages  in  a  stricture  far  more 
gently  than  the  sharp-edged  urethroscope.  Hence,  the  sound  to  be 
used  should  be  several  sizes  larger,  viz.,  about  26  F. 

This  distinction  between  an  infiltration  of  large  caliber  and  one  of 
small  caliber  is  not  an  artificial  one,  for  the  gonorrheal  scar  that  does 
not  offer  any  impediment  to  the  passage  of  a  23  F.  urethroscope,  or 
26  F.  sound,  is  so  slight  a  scar  and  impedes  the  outflow  of  urine  so 
little  that  the  congestion  upon  its  surface  is  likely  to  remain  slight;  and 
even  though  untreated,  it  may  probably  (and  in  some  cases  certainly) 
cause  no  stricture,  no  real  constriction  of  the  urethra,  even  after  many 
years. 

Moreover,  the  diagnosis  or  treatment  of  these  infiltrations  of  the 
first  degree  is  rather  that  of  the  urethritis  which  they  maintain  than  of 
the  scar  itself.  They  are  diagnosed  by  the  urethroscope  and  the 
bulbous  bougie,  while  the  true  or  tighter  strictures  may  be  better 
diagnosed  by  the  sound.  They  are  treated  largely  for  the  purpose  of 
curing  the  urethritis  upon  them  and  behind  them,  with  the  assurance 
that  if  this  urethritis  is  thoroughly  cured  the  infiltration  of  the  first 
degree  will  show  no  further  tendency  to  contract  and  the  urethritis  no 
more  than  a  very  remote  tendency  to  relapse. 

Thus  we  may  dismiss  the  whole  subject  of  infiltration  of  the  first 
degree  to  the  topic  of  chronic  anterior  urethritis,  where  it  properly 
belongs.  With  it  we  dismiss  the  theory  of  strictures  of  large  caliber, 
promulgated  fifty  years  ago  by  Otis,  and  which  for  a  quarter  of  a 
century  dominated  the  treatment  of  chronic  urethritis  in  this  country. 

Otis's  claim  that  the  urethra  is  an  evenly  calibrated  tube,  bearing  a 
certain  relation  to  the  size  of  the  penis,  is  too  fantastical  and  medieval 
even  to  require  discussion  at  this  day.  His  routine  practice  of  cutting 
the  urethra  to  such  size  as  40  and  45  F.  cannot  be  too  thoroughly  con- 
demned as  a  routine,  for  the  knife  should,  as  far  as  possible,  be  replaced 
by  the  dilator,  and  the  object  of  treatment  of  infiltration  of  the  first 
degree  should  be,  not  the  dilatation  of  the  urethra  to  a  theoretical 
limit,  but  the  cure  of  chronic  urethritis,  by  whatever  dilatation  is 
necessary  to  that  end.  In  exceptional  cases  internal  urethrotomy 
is  required  for  the  treatment  of  chronic  urethritis  just  as  much  today 
as  it  ever  was. 

Statistics. — Our  knowledge  of  the  pathology  of  urethral  stricture  is 
founded  upon  the  researches  of  Sir  Henry  Thompson  on  stricture  itself, 
and  those  of  Oberlaender,  in  Vienna,  and  of  Wassermann  and  Halle,  in 
Paris,  on  chronic  urethritis  and  the  inflammatory  process  which  leaves 
the  scar  we  call  stricture.  Upon  this  basis  of  pathological  fact  we  shall 
found  our  clinical  observations. 

These  relate  to  583  cases  of  gonorrheal  stricture,  55  cases  of  traumatic 
stricture,  a  large  number  of  congenital  strictures,  almost  all  at  the 
meatus,  and  a  few  due  to  tuberculosis,  syphilis,  and  other  causes.  The 
mere  number  of  these  cases  might  be  equalled  in  the  case  books  of  any 
urologist,  but  their  interest  arises  from  the  fact  that  almost  all  of  them 

M  u     i — 25 


386  STRICTURE  OF  THE   U  RET  Hit  A 

were  private  patients*  whose  condition  was  noted  with  care  for  a 
considerable  number  of  years.  Of  no  less  than  120  we  have  records 
extending  over  ten  years  or  more,  while  of  one-half  of  these  (62  to  be 
accurate)  the  records  extend  for  twenty  years  or  more.  Thus  we  are 
able  to  estimate  the  progress  of  this  disease  and  the  result  of  its  treat- 
ment rather  more  accuratelv  than  has  been  heretofore  done. 


GONORRHEAL  STRICTURE  OF  THE  MALE  URETHRA. 

Gonorrheal  stricture  of  the  urethra  is  a  scar  in  the  wall  of  the  canal 
produced  by  gonorrheal  inflammation  of  its  glands — a  scar  of  sufficient 
extent  to  grasp  a  26  F.  sound. 

Etiology. — The  cause  of  gonorrheal  stricture  is  not  simply  gonorrhea. 
Indeed,  stricture  very  rarely  follows  a  well-treated  gonorrhea.  The 
relative  frequency  of  stricture  in  the  clinic  as  compared  to  private 
practice  is  evidence  that  neglect  and  the  trauma  of  unskilful  local 
treatment  play  a  large  part  in  its  etiology. 

Thus  sometimes  the  brutal  breaking  of  a  chordee,  or  the  clumsy 
passage  of  a  sound  actually  tears  the  mucosa  and  produces  a  stricture 
that  is  more  traumatic  than  gonorrheal.  Yet,  as  a  rule,  the  trauma  is 
only  a  subsidiary  cause.  The  careless  instrumentation  or  overfrequent 
injection  merely  intensifies,  instead  of  lessening,  the  infection,  inflames 
the  urethral  glands  more  severely,  increases  the  periglandular  exudate, 
and  thus  produces  more  scar,  more  stricture. 

Stricture  is  due  rather  to  intensity  than  to  duration  of  urethritis.  To 
be  sure,  Wassermann  and  Hallef  long  ago  proved  chronic  anterior 
urethritis  a  sclerotic  process;  but  their  inference  that  stricture  is  due 
to  chronic  urethritis  is  not  justified,  for  the  extent  of  the  sclerosis  in 
chronic  urethritis  is  determined,  not  by  the  duration  of  chronic  inflam- 
mation— ancient  anterior  urethritis  without  stricture  is  a  commonplace 
observation — but  by  the  acute  outbreaks  that  precede  or  interrupt  it. 
Stricture  and  chronic  urethritis  have  a  common  cause.  They  do  not 
cause  each  other;  though  stricture  keeps  up  the  inflammation,  while 
this  in  turn  adds  to  the  scar. 

Pathology. — Gonorrheal  stricture  is  but  a  cicatrization  of  the  patho- 
logical process  that  causes  chronic  anterior  urethritis.  The  pathology 
of  stricture  begins,  as  it  were,  where  that  of  the  active  inflammation 
leaves  off.  Gonorrheal  anterior  urethritis  becomes  chronic  through 
continued  suppuration  in  the  glands  of  the  urethra.  The  glands  con- 
tinue to  suppurate  because  of  bad  drainage,  their  ducts  being  obstructed 
by  the  inflammatory  exudate  in  the  urethral  wall.  This  inflammatory 
periadenitis  varies  in  extent  and  intensity;  sometimes  a  mere  swelling 
of  the  mucosa  itself,  sometimes  extending  with  the  glands,  and  beyond 

*  From  our  hospital  records  we  have  borrowed  only  the  operative  statistics  of  perineal 
section. 

t  We  assume  the  reader's  familiarity  with  the  phenomena  of  chronic  urethritis, 
described  in  Chapter  IX. 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       387 

the  glands,  into  the  surrounding  corpus  spongiosum,  and  even  beyond 
this  into  the  subcutaneous  tissue.  These  processes  have  been  described 
in  reference  to  gonorrhea.  Suffice  it  to  state  that  the  mildest  of 
them  results  in  superficial  scarring  of  the  mucosa,  which  at  most  can 
only  cause  a  slight  contraction  of  the  urethra.  The  more  extensive 
and  intensive  processes  result  in  grave  stricture,  peri-urethral  abscess, 
fistula,  etc. 

With  the  cicatrization  of  this  peri-urethral  exudate  a  scar  is  formed  in 
the  urethral  wall.  This  contains  a  large  proportion  of  elastic  fibers. 
It  tends  to  contract.  It  diminishes  the  lumen  of  the  urethra.  At  first 
the  actual  encroachment  upon  the  urethral  lumen  is  slight,  but  the 
physiological  impairment  is  great.  The  outflow  of  the  urinary  stream 
meets  an  obstacle  in  this  rigid  portion  of  the  urethral  wall,  an  obstacle 
that  continues  to  harbor  gonococci  or  other  bacteria  in  its  inflamed 
glands,  and  whose  surface  is  eroded  or  ulcerated.  Repeated  impact  of 
the  urinary  stream  against  this  tends  to  dilate  the  urethra  behind  it 
and  to  intensify  the  chronic  urethritis  about  it.  As  a  result,  more  peri- 
glandular  exudate  is  formed,  more  scar  results,  the  urethral  lumen  is 
still  further  narrowed,  while  the  chronic  urethritis  is  encouraged.  The 
complications  of  anterior  urethritis,  viz.,  peri-urethritis  and  peri- 
urethral  phlegmon,  abscess,  and  fistula,  are  common  results  of  neglected 
stricture. 

Urinary  sepsis  due  to  retention  and  infection  of  the  upper  urinary 
tract  results  from  stricture,  just  as  it  does  from  prostatism  (q.  fl.) ;  but 
inasmuch  as  the  patient  with  stricture  is  usually  several  decades  younger 
than  the  possessor  of  an  enlarged  prostate,  his  younger  and  stronger 
muscles  tell  in  his  favor.  His  bladder  is  more  likely  to  become  hyper- 
trophied  (sclerosis  with  thickening  of  the  wall,  but  without  dilatation 
of  the  cavity)  than  atrophied.  If  relieved  of  his  stricture,  even  after 
his  kidneys  have  suffered  grave  damage,  his  expectation  of  life  may  be 
considerable. 

Postmortem  examination  of  urethral  stricture  may  only  reveal  a 
transverse  scar  in  the  mucosa  so  slight  that  it  can  be  felt  rather  than 
seen  when  the  urethra  is  split  open.  The  surface  of  the  mucosa  may  look 
normal;  it  may  be  eroded,  granulating,  pouched  from  back  pressure,  or, 
in  the  more  extreme  cases,  utterly  distorted  by  irregular  masses  of  scar 
and  areas  of  suppuration. 

Location  of  Stricture.  —  In  the  preceding  paragraphs  gonorrheal 
stricture  has  been  described  as  though  it  affected  the  anterior  urethra 
exclusively.  Such  is  not  the  case.  Gonorrheal  stricture  of  the  mem- 
branous urethra  has  been  observed,  and  one  occasionally  operates  upon 
a  urethra  strictured  not  only  from  meatus  to  bulb  but  also  throughout 
the  posterior  urethra. 

Gonorrheal  stricture  of  the  posterior  urethra  does  not,  however,  con- 
cern us  here.  Its  one  important  clinical  expression,  viz.,  stricture  at 
the  neck  of  the  bladder,  gives  the  symptoms  of,  and  is  therefore  dealt 
with  in  connection  with,  prostatism.  Stricture  of  the  remainder  of  the 
membranous  and  prostatic  urethrte  is  never  seen  alone;  it  is  but  a 


388  STRICTURE  OF  THE   URETHRA 

complication  of  graver  stricture  in  the  bulb.*  With  the  exception  of 
stricture  at  the  neck  of  the  bladder,  gonorrheal  strictures  of  the  posterior 
urethra  may  therefore  be  dismissed  with  the  statement  that  they  add 
nothing  to  the  clinical  picture  or  to  the  treatment  of  gonorrhea  of  the 
anterior  urethra.  They  appear  indeed  to  be  singularly  amenable  to 
dilatation. 

In  the  anterior  urethra,  gonorrheal  stricture  is  coterminous  with 
gonorrheal  urethritis,  with  the  urethra  itself.  An  utterly  neglected  case 
thus  sometimes  presents  irregular  bands  of  stricture  at  short  intervals 
from  one  end  of  the  urethra  to  the  other.  But  such  cases  are  rare.  The 
symptoms  of  neglected  stricture  usually  cry  for  relief  long  before  so 
extensive  a  process  can  develop. 

In  the  majority  of  cases  strictures  are  pathologically  single,  though 
they  may  be  clinically  multiple,  i.  e.,  there  is  but  a  single  scar  affecting 
a  greater  or  less  extent  of  the  urethra,  upon  the  surface  of  which  there 
may  be  one  or  more  ridges  presenting  points  of  obstruction  to  the 
examining  instrument.  Hence  the  clinician  notes  the  frequency  of 
multiple  strictures  while  the  pathologist  asserts  their  rarity  in  that 
very  class  of  (postmortem)  cases  in  which  their  multiplicity  should  be 
most  apparent.  Thus  Thompson10  found  only  41  cases  of  multiple 
stricture  among  270  museum  specimens.  Only  8  of  these  extended 
throughout  the  urethra. 

Thompson10  suggests  the  following  division  of  the  urethra  for  the 
classification  of  gonorrheal  strictures: 

1.  "The  bulbomembranous,  from  one  inch  in  front  of  to  three- 
quarters  of  an  inch  behind  the  junction  of  the  spongy  with  the  mem- 
branous urethra.     This  region  contains  the  majority  of  strictures; 
they  lie  rather  in  front  of  than  behind  the  junction  of  the  bulb  with  the 
membranous  urethra. 

2.  "From  the  anterior  limit  of  region  1  to  within  "2\  inches  of  the 
meatus." 

3.  "The  terminal  1\  inches  of  the  canal." 

Thompson  found  215  (67  per  cent.)  strictures  in  region  I,  51  (16 
per  cent.)  in  region  II,  54  in  region  III.  Among  564  of  our  cases  345 
(61  per  cent.)  were  in  region  I. 

The  Form  of  Stricture. — It  is  convenient  to  speak  of  linear,  annular,  or 
tortuous  strictures.  These  terms  correspond  to  clinical  characteristics. 

Two  more  important  points  in  reference  to  the  form  of  stricture  must 
be  borne  in  mind :  In  the  first  place  the  scar  of  stricture  is  built  up 
chiefly  from  the  floor  of  the  urethra.  Its  orifice  is  therefore  eccen- 
trically placed  and  usually  near  the  roof  of  the  canal. 

In  the  second  place,  irregular,  multiple  strictures  usually  become 
progressively  narrower  as  they  approach  the  bulb.  Even  though  the 
stricture  extends  over  only  a  short  portion  of  the  urethra,  its  tightest 
point  is  likely  to  be  the  deepest;  while  if  its  extent  is  considerable, 

*  Thompson  states  that  while  stricture  is  most  common  in  the  bulb,  "the  liability 
of  this  part  to  stricture  appears  to  diminish  as  it  approaches  the  (bulbomembranous) 
junction,  where  it  is  less  common,  while  behind  it  is  very  rare." 


GONORRHEAL  STRICTURE  OF   THE  MALE   URETHRA       389 

examining  instruments  impact  upon  tighter  and  tighter  bands  until  the 
tightest  point  of  all  is  found  in  the  deeper  portion  of  the  bulb.  Thus  the 
minimum  size  noted  by  us  in  459  cases  is  shown  in  the  subjoined  table: 

In  regions  II  and  III.  In  region  I. 

Impassible 3  35 

Filiform        to    9  F 21  131 

10  to  19  F 68  88 

20  to  26  F 62  51 

154  305 

Hence,  of  the  anterior  strictures,  less  than  16  per  cent,  contracted 
below  10  F.,  while  of  the  perineal  strictures,  54  per  cent,  did  so.  An- 
terior strictures  contract  to  a  far  less  degree  than  perineal  strictures. 

This  is  doubtless  due  to  the  fact  that  rapidity  of  contraction  in  a 
stricture  is  in  proportion  to  the  irritation  to  which  it  is  subjected,  the 
band  of  scar  nearest  the  bladder  receiving  the  full  impact  of  the  urinary 
stream,  thus  contracts  most  rapidly.  , 

Symptoms. — The  symptoms  of  urethral  stricture,  like  those  of  pros- 
tatic  retention,  may  bear  little  relation  to  the  gross  pathological  con- 
dition. Thus  a  patient  complaining  only  of  a  chronic  urethral  dis- 
charge may  be  found  to  suffer  from  an  extensive  and  very  tight  stricture; 
while  another  who  suffers  from  acute  complete  retention  of  urine  may 
have  but  a  single  narrow  band  that  obstructs  the  urethra  rather  by 
congestion  than  by  actual  contraction  of  scar.  Furthermore,  the  most 
treacherous  stricture  cases  resemble  those  cases  of  prostatism  of  which 
the  local  symptoms  are  few,  but  whose  general  debility,  resulting  from 
mild  chronic  urinary  septicemia,  may  bring  them  to  a  state  of 
incurable  renal  deficiency  before  they  even  consult  a  physician. 

Onset. — The  accompanying  table  compiled  from  our  cases  and  those 
of  Sir  Henry  Thompson  shows  that  the  symptoms  of  stricture  usually 
begin  within  one  year  of  the  gonorrhea  causing  it.  Exceptionally,  and 
doubtless  through  neglect  on  the  part  of  the  patient  to  be  thoroughly 
treated  for  a  chronic  urethritis,  the  slight  scar  resulting  from  this  may, 
after  many  years,  result  in  true  stricture. 

Keyes.     Thompson.      Total.      Per  cent. 

Within  1  year 121  81  202  54 

1  to    5  years 38  41  79  21 


6  to  10 
11  to  15 
16  to  20 
21  to  30 
Over  30 


27  22  49  13 

7  20  27  7 

808] 
909 
202 

212  164  376 


It  will  be  noted  that  Thompson's  cases,  founded  upon  pathological 
observation,  average  a  much  earlier  onset  than  ours,  founded  upon 
clinical  data.  Doubtless  his  figures  are  the  more  correct. 

The  Initial  Symptom.— We  have  tabulated  the  initial  symptom  of 
422  of  his  cases  with  the  following  result: 


390  STRICTURE  OF  THE   URETHRA 

Chronic  urethral  discharge 238 

Obstruction  to  urination 77 

Frequency  of  urination 53 

Acute  complete  retention  of  urine 31 

Pain 8 

Peri-urethritis 7 

Hemorrhage 3 

Overflow  from  retention 2 

Persistent  chordee 2 

Epididymitis  (symptoms  of) 2 

Pyonephrosis  (symptoms  of) 1 

This  list  will  bear  various  interpretations.  It  suggests  among  other 
things  that  some  patients  are  far  more  alert  to  observe  their  symptoms 
than  others;  that  the  symptoms  of  catarrh  usually  antedate  those  of 
obstruction ;  that  the  obstruction  may  come  on  so  gradually  as  not  to 
fix  the  patient's  attention  until  it  has  become  complete  or  until  the 
hemorrhage  from  an  ulcer,  or  the  pain  and  fever  from  a  secondary 
infection  of  kidney  or  epididymis,  clamor  for  relief. 

Chronic  Urethral  Discharge. — The  chronic  urethral  discharge  of 
stricture  (commonly  called  gleet)  is  usually  little  more  than  a  drop  of 
pus  at  the  meatus  in  the  morning.  By  the  time  definite  stricture 
develops,  gonococci  are  likely  to  have  disappeared  and  been  replaced 
by  other  bacteria.  The  urine  passed  always  contains  shreds,  and  these 
are  usually  of  considerable  size.  These  shreds  are  derived  from  the 
inflamed  or  ulcerated  surface  of  the  stricture  and  the  adjacent  portions 
of  the  urethra. 

The  presence  of  free  pus  enough  to  cloud  the  urine  depends  upon  a 
superadded  urethritis,  prostatitis,  or  infection  of  the  upper  urinary 
tract.  It  should  be  borne  in  mind  that  large  shreds  are  suggestive 
of  stricture,  while  free  pus  in  the  urine  is  to  be  referred  to  the  inflamma- 
tion accompanying  stricture. 

Frequent  and  Obstructed  Urination.- — As  the  stricture  grows  tighter 
the  act  of  micturition  requires  more  effort  and  the  last  drops  of  urine 
dribble  away.  Chronic  urethritis  is  kept  up  and  this  inflammation 
extends  to  the  prostate.  The  resulting  irritation  and  infection  of  the 
prostate,  bladder,  and  kidneys  cause  frequent  and  painful  urination. 
These  symptoms  are  by  no  means  pathognomonic  of  stricture.  Indeed, 
the  dysuria  due  to  infection  may  quite  overshadow  the  sense  of 
obstruction  due  to  stricture. 

Changes  in  the  shape  or  the  force  of  the  urinary  stream  may  be  due  to 
so  many  conditions  other  than  stricture  that  they  deserve  no  special 
notice.  The  split  or  deflected  stream  is  usually  due  to  a  drop  of  mucus 
in  a  tight  meatus.  The  shape  of  any  stream  is  imparted  to  it  by  the 
nozzle  from  which  it  flows. 

Acute  Retention. — Acute  complete  retention  of  urine  (sudden  com- 
plete— or  almost  complete — occlusion  of  the  urethra)  is  due  to  the 
sudden  congestion  of  a  canal  already  partially  obstructed  by  stricture. 
This  congestion  is  similar  to  the  like  condition  complicating  prostatic 
retention,  and  is  attributable  to  like  causes,  e.  g.,  voluntary  retention  of 
urine,  alcoholism,  exposure  to  cold,  etc.  Though  the  stricture  is  usually 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       391 

very  tight,  I  have  seen  cases  of  acute  complete  retention  of  urine  due  to 
stricture  that  readily  admitted  a  20  F.  sound.  Moreover,  it  is  a 
commonplace  observation  that  the  patient  whose  stricture  is  so  tight 
that  no  instrument  can  be  passed  through  it  may  yet  retain  his 
ability  to  urinate,  refuse  further  treatment,  and  go  several  months  or 
years  before  acute  retention  occurs. 

The  retention  due  to  stricture  differs  in  one  most  important  particu- 
lar from  that  due  to  prostatism.  Either  condition  may  cause  acute 
complete  retention,  but  partial  retention  is  not  caused  by  urethral 
stricture  unless  that  stricture  is  complicated  by  some  form  of  prostatic 
retention,  such  as  prostatic  abscess  or  stricture  at  the  neck  of  the 
bladder.  Hence,  the  kidneys  of  a  patient  with  stricture  defy  neglect  in 
spite  of  repeated  attacks  of  acute  complete  retention  for  a  much  longer 
time  than  those  of  the  victim  of  prostatic  retention.  For  the  strictured 
urethra,  if  it  permits  the  bladder  to  empty  at  all,  permits  it  to  empty 
completely.  A  large  proportion,  perhaps  a  majority,  of  attacks  of  acute 
retention  with  stricture  are  relieved  almost  spontaneously.  The 
patient  at  first  vainly  struggles  to  urinate.  If  inexperienced,  he 
promptly  becomes  panic-stricken  and  increases  his  agony  by  struggling 
to  overcome  what  is  for  the  moment  an  insurmountable  obstacle.  The 
torturing  spasms  recur  every  few  moments  until  a  physician  brings 
relief,  or  the  spasm  relaxes  and  a  dribbling,  hesitating  stream  gradually 
relieves  the  retention.  (The  third  possible  alternative,  viz.,  death  by 
exhaustion  or  rupture  of  the  bladder,  I  have  never  seen.) 

The  experienced  victim,  on  the  other  hand,  recognizes  the  thin  stream 
that  foretells  retention  and  takes  his  precautions  accordingly.  He  re- 
strains his  efforts  to  urinate,  lies  down,  takes  a  hot  hip-bath,  and  so  often 
wards  off  the  attack.  Yet  these  palliatives  sometimes  fail,  and  he,  too, 
has  to  summon  professional  aid. 

The  recurrence  of  acute  retention  depends  more  on  the  accident  of 
congestion  than  the  tightness  of  the  stricture.  Most  patients  who  have 
had  complete  retention  may  look  for  repeated  relapses  at  intervals  of 
a  few  weeks  or  months  unless  they  submit  to  dilatation.  But  excep- 
tionally they  escape  for  an  extraordinary  length  of  time.  Thus,  I  have 
records  of  one  patient  who  had  but  three  acute  retentions  in  eight  years, 
though  never  dilated.  Another  had  a  single  retention  (undilated)  ten 
years  before  he  came  for  treatment.  A  third,  discouraged  by  the  failure 
of  any  instrument  to  pass  his  stricture,  consulted  no  physician  and  had 
no  retention  for  fifteen  years  thereafter.  But  such  reprieves  are  neither 
to  be  expected  nor  to  be  desired.  During  these  years  the  destructive 
effects  of  renal  retention  and  infection  progress  silently  but  steadily. 

Hemorrhage.- — Apart  from  the  bleeding  excited  by  instrumentation, 
or  resulting  from  acute  prostatitis,  hemorrhage  is  a  rare  symptom  of 
stricture.  It  is  likely  to  occur  early,  to  be  quite  profuse,  to  assume  the 
form  of  urethrorrhagia  (hemorrhage  between  the  acts  of  urination), 
with  more  or  less  hematuria.  The  bleeding  during  urination  is  likely 
to  be  terminal  (most  marked  toward  the  end  of  the  act).  This  bleed- 
ing, like  that  of  fissure  in  ano,  is  due  to  ulceration,  and  is  promptly 


302  STRICTURE  Of  nil-    ri:KTin;.\ 

and  brilliantly  controlled  by  dilatation.  The  passage  of'  a  Dingle  sound 
may  promptly  control  profuse  hemorrhage.  Such  hemorrhage  was 
noted  three  times  as  the  initial  symptom,  and  in  four  other  of  our  cases 
as  a  striking  symptom. 

Sexual  Symptoms. — The  sexual  deficiency,  the  impotence,  the  neu- 
rasthenia, and  the  various  pains  radiating  from  the  prostate  and  seminal 
les,  that  were  attributed  by  a  preceding  generation  to  urethral 
stricture,  are  much  more  commonly  seen  in  patients  who  have  no  stric- 
ture whatever,  and  are  themselves  rarely  directly  referable  to  stricture. 
Tight  stricture  does,  indeed,  often  cause  inflammation  of  the  coliculus, 
the  prostate,  or  the  vesicles  such  as  will  interfere  with  their  function: 
but  it  is  rare  that  these  symptoms  should  not  be  relieved  by  dilatation 
of  the  stricture. 

Pain. — Various  types  of  pain  result  from  stricture:  Painful  urination 
has  been  alluded  to.  Painful  erection  amounts  practically  to  chordee 
in  some  cases  of  extensive  stricture  in  the  region  of  the  penoscrotal 
angle  if  accompanied  by  considerable  inflammation.  Perineal  and 
other  pains  are  due  to  the  accompanying  or  resulting  inflammations  of 
the  internal  sexual  organs. 

Complications  of  Stricture.  —  Prostatiiis  and  Vesiculitis.  —  These 
complications  are  so  common  as  to  be  almost  part  of  the  usual  clinical 
picture  of  the  disease. 

Renal  Retention  and  Infection. — We  have  already  insisted  that  the 
silent  progress  of  renal  infection,  sclerosis  and  dilatation,  is  the  most 
insidious  and  dangerous  complication  of  stricture.  It  is  the  cause  of 
urethral  chill  and  urinary  septicemia  (whether  or  not  excited  by  the 
passage  of  instruments) ,  and  of  almost  all  the  deaths  resulting  from  the 
stricture  itself  or  from  its  treatment.  Unnumbered  lives  are  shortened 
through  reduction  of  renal  efficiency.  Even  though  the  stricture  itself 
be  properly  controlled,  the  resulting  renal  lesion  permanently  impairs 
the  resistance  of  its  host  to  such  hardships,  accidents  and  maladies  as 
he  may  encounter. 

Xo  statistics  can  convey  the  precise  importance  of  these  secondary 
renal  lesions.  The  least  we  can  do  is  to  be  always  on  the  alert,  to 
include  them  in  our  diagnosis,  and  to  make  allowance  for  them  in  our 
treatment. 

Peri-urethritis  and  Prostatic  Abscess. — Peri-urethral  phlegmon  and 
suppuration  either  at  the  site  of  stricture,  or  arising  from  the  prostate 
or  Cowper's  glands,  was  noted  in  52  of  our  cases.  The  course  and 
treatment  of  these  complications  do  not  materially  dift'er  from  those 
described  as  complications  of  gonorrheal  urethritis  (p.  304). 

Epididymitis. — Infection  of  the  epididymis,  as  a  result  of  urethral 
stricture,  is  usually  the  work  of  the  bacillus  coli  or  of  the  pyogenic  cocci. 
Hence  it  is  much  more  likely  to  suppurate  than  is  gonorrheal  epididy- 
mitis.  Although  this  complication  discourages  urethral  instrumenta- 
tion, it  may  nevertheless  be  imperative  to  relieve  a  tight  stricture,  even 
in  the  presence  of  an  acutely  inflamed  epididymis.  Under  such  con- 
ditions the  complication  may  sometimes  prove  an  argument  whereby 


GOXORRHEAL  STRICTURE  OF   THE   MM. I-    URETHRA       IVM\ 

the  surgeon  may  persuade  the  patient  to  submit  to  perineal  section 
together  with  drainage  of  the  epididymis. 

Other  Complications. — Among  the  rarer  complications  noted  in  our 
cases,  we  may  mention  2  cases  of  prostatic  stone,  3  of  bladder  stone,  and 
2  of  stone  in  the  kidney.  Rheumatism  was  only  once  noted.  One 
would  fancy  its  actual  frequency  much  greater  than  this. 

Complications  Due  to  Treatment. — Among  the  most  important  com- 
plications of  urethral  stricture  are  those  resulting  from  improper  treat- 
ment. Too  great  brutality  in  passing  instruments  may  result  in  added 
scar,  urethral  chill,  urinary  septicemia,  epididymitis,  peri-urethritis, 
prostatic  abscess.  Failure  to  enter  the  stricture  may  result  in  false 
passage  and  peri-urethritis.  Enthusiastic  internal  urethrotomy  may 
result  in  permanent  incurvation  of  the  penis,  of  which  5  cases  appear 
upon  our  list. 

Course  and  Prognosis. — Inasmuch  as  the  clinical  picture  of  gonorrheal 
urethral  stricture  is  a  composite  of  scar  and  inflammation,  more  or  less 
controllable  by  treatment  and  subject  to  the  vicissitudes  of  intercurrent 
gonorrheas  and  other  sources  of  irritation,  it  is  obviously  quite  impossible 
to  compose  a  picture  that  shall  adequately  represent  the  usual  course 
of  this  disease.  Slight  chronic  urethral  discharge  may  be  for  many 
years  the  only  symptom,  while  yet  again  it  may  be  absent  altogether, 
and  only  the  large  shreds  in  the  urine  suggest  the  presence  of  stricture. 
Retentions  may  be  frequent  and  rapidly  recurrent.  Yet  exceptionally 
a  single  retention,  relieved  without  any  real  treatment  of  the  stricture, 
may  be  followed  by  an  interval  of  years  before  retention  recurs.  Per- 
haps the  interval  between  the  appearance  of  symptoms  suggesting 
stricture  and  the  beginning  of  treatment,  will  hint,  as  well  as  figures 
can,  how  various  is  the  progress  of  this  malady. 

We  have  tabulated  the  time  at  which  treatment  was  begun  in  285 
cases. 

Cases.  Per  cent. 

Within  six  months 68  1  «9 

From  six  to  twelve  months 22  j 

During  second  year 27 1  „(• 

"       third  to  fifth  year 77  / 

"      sixth  to  tenth  year 39 

"      eleventh  to  twentieth  year     .      .      .      .      .      .      .39 

Beyond  twentieth  year 13 

Yet  in  all  this  uncertainty  there  is  some  regularity  of  prospect  which 
may  be  sketched  as  follows: 

The  progress  of  stricture  is  measured  by  the  promptness  and  inten- 
sity of  its  onset  on  the  one  hand,  opposed  by  the  efficiency  of  treatment 
on  the  other.  Thus  a  stricture  that  has  for  its  only  symptom  a  mild 
gleet,  or  that  begins  many  years  after  the  last  gonorrhea,  is  likely  to  be 
a  slight  scar,  to  contract  slowly  and  may  perhaps  be  neglected  with 
impunity  for  a  considerable  period .  On  the  other  hand ,  a  stricture  that 
begins  early  and  with  symptoms  of  obstruction  or  retention  is  likely  to 
be  a  dense  scar  and  to  progress  rapidly. 

Furthermore,  acute  retention  of  urine,  whether  relieved  by  dilatation 
or  not,  usually  recurs  within  a  year,  if  the  stricture  is  neglected. 


394  STRICTURE  OF   THE    URETHRA 

Strictures  of  the  pendulous  urethra  contract  more  slowly,  and  even 
\vhen  neglected,  to  a  less  degree  than  those  in  the  bulb.  Yet  (as  we  shall 
see)  strictures  of  the  bulb  are  far  more  amenable  to  dilatation  than  those 
of  the  anterior  urethra. 

Although  in  the  absence  of  intercurrent  gonorrhea  acute  prostatic 
or  renal  suppuration  are  rarely  seen  before  the  stricture  has  become 
very  tight,  peri-urethral  phlegmon  and  suppuration  may  result  from 
a  stricture  of  relatively  large  caliber. 

Cure. — Inasmuch  as  stricture  is  scar,  it  cannot  be  cured.  Inasmuch  as 
it  is  a  constricting  scar,  it  may  be  cured  if  the  constriction  is  sufficiently 
dilated  to  overcome  the  tendency  to  recontract,  and  so  long  as  inter- 
current  urethritis  does  not  excite  further  scar  formation,  thus  inducing 
recontraction. 

Since  an  alleged  cure  of  stricture  must  be  surrounded  by  so  many 
conditions,  it  is  impossible  to  assure  any  patient  with  absolute  certainty 
that  his  stricture  will  never  recontract.  But  in  this  matter  the  dis- 
tinction between  stricture  of  the  bulb  (Thompson's  region  III)  on  the 
one  hand  and  stricture  of  the  pendulous  and  scrotal  urethra  (Thomp- 
son's regions  I  and  II)  on  the  other  is  striking. 

The  deeper  strictures,  though  they  can  often  be  readily  dilated,  show 
an  almost  universal  tendency  to  recontract.  A  fully  dilated  stricture  is 
likely  to  recontract  to  the  point  of  giving  retention  in  from  one  to  five 
years.  Exceptionally  the  recontraction  is  slow,  so  that  even  ten  to 
fifteen  years  later  a  small  sound  can  still  be  passed,  while  most  ex- 
ceptionally the  stricture  does  not  recontract  at  all.  At  least  I  have 
followed  several  cases  for  more  than  ten  years  that  showed  no  evidence 
of  recontraction.4 

Stricture  of  the  bulbous  and  scrotal  urethra,  on  the  other  hand,  if  it 
has  once  formed  a  dense  scar,  is  very  rebellious  to  dilatation;  but  when 
cut  to  no  larger  size  than  32  or  34  F.  may  usually  be  kept  widely  dilated 
by  the  passage  of  sounds,  and  if  this  treatment  is  continued  until  the 
cut  has  healed  and  the  adjacent  urethritis  is  cured,  no  further  recon- 
traction of  such  a  stricture  need  be  feared.  It  is  not  to  be  forgotten, 
however,  that  such  strictures  are  often  accompanied  by  stricture  of  the 
bulbous  urethra.  This  shows  the  usual  tendency  to  recontract. 

Diagnosis. — The  diagnosis  of  urethral  stricture  must  include  the 
diagnosis  of  chronic  anterior  urethritis  and  of  such  complications  as 
peri-urethritis,  prostatic  abscess,  renal  infection  and  retention,  etc., 
since  the  presence  of  these  materially  influence  the  prognosis  and 
treatment. 

Moreover,  the  diagnosis  of  stricture  itself  contains  an  element  of 
prognosis;  for  one  must  determine  not  only  whether  actual  stricture 
exists,  but  whether  stricture  is  likely  to  occur,  or,  if  previously  existing 
and  under  control,  to  recur. 

History  and  urinalysis  are  of  value  in  the  correlation  of  diagnosis. 
But  for  a  precise  diagnosis  \ve  depend  upon  the  examination  of  the 
patient. 

Asepsi-s  and  Anesthesia. — The  diagnosis  of  stricture  is  made  by  the 
introduction  of  instruments  into  an  inflamed  canal.  Among  the  most 


(iONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       395 

important  results  of  stricture  are  pyelonephritis  and  pyonephrosis. 
The  capacity  of  infected  kidneys  to  withstand  shock  may  be  gravely 
impaired,  though  the  patient  may  appear  in  smiling  health.  The 
passage  of  sounds  is  peculiarly  qualified  to  excite  an  acute  suppurating 
nephritis.  Therefore  the  precautions  elsewhere  laid  down  for  urethral 
asepsis  and  antisepsis  must  be  most  minutely  observed.  Instruments 
must  be  passed  with  the  greatest  gentleness,  and  it  is  actually  a  measure 
of  precaution  to  precede  the  passage  of  urethral  instruments  by  an 
injection  into  the  urethra  of  1  per  cent,  novocain  solution,  to  be  retained 
at  least  15  minutes  before  the  instruments  are  introduced.  This  is 
grateful  to  the  patient,  for  it  diminishes  his  pains;  and  it  should  be 
taken  advantage  of  by  the  surgeon.  He  should  be  more  than  gentle. 
It  lessens  the  spasm  of  the  urethral  muscles,  makes  the  passage  of 
instruments  mechanically  much  easier,  and  diminishes  the  subsequent 
reaction. 

The  Urethroscope. — The  urethroscope  which  is  so  useful  for  the  pre- 
cise diagnosis  of  chronic  anterior  urethritis  may  also  be  employed  for 
the  diagnosis  of  stricture.  The  straight  open-end  tube  should  be  used. 
If  the  stricture  is  large  enough  to  admit  the  tube,  the  urethral  wall  is 
seen  to  be  rigid  in  that  it  does  not  fall  together  into  the  usual  radiat- 
ing folds.  Indeed  the  scar,  if  dense,  holds  the  urethra  relatively  open 
on  the  end  of  the  urethroscope.  The  surface  of  the  mucous  mem- 
brane is  usually  inflamed,  eroded  and  even  ulcerated,  most  markedly 
at  the  point  of  stricture  and  to  a  less  degree  both  before  and  behind 
this.  If  the  surface  inflammation  is  under  control,  however,  the 
mucosa  looks  shiny,  whiter  than  normal  and  quite  bereft  of  its  usual 
folds. 

The  tight  stricture  which  will  not  admit  the  urethroscopic  tube  usually 
bleeds  so  freely  that  the  examination  is  of  little  value. 

The  Olivary  Bougie. — This  is  the  favorite  instrument  for  the  diagnosis 
of  stricture.  With  a  complete  set  of  bougies  (from  6  to  26  F.)  one  may 
diagnose  with  accuracy  the  size  of  the  various  constrictions  in  the 
anterior  urethra.  Filiform  strictures  elude  precise  diagnosis  by  the 
bulbous  bougie,  but  all  other  constrictions  are  perceptible  as  bands 
through  which  the  bulb  of  appropriate  size  slips  with  a  jump. 

The  urethrometer  of  Otis  theoretically  gives  the  most  accurate  picture 
of  urethral  constrictions.  I  have  never  employed  it. 

Sounds  and  Bougies. — The  urethroscope  gives  a  picture  of  the  surface 
lesions  of  the  canal.  The  bulbous  bougie  gives  precise  information  as 
to  the  tightness  of  each  stricture  band.  The  sound  and  the  bougie  do 
not  give  such  precise  information,  but  they  do  tell  us  that  stricture  does 
or  does  not  exist.  They  inform  us  as  to  its  approximate  diameter  and 
dilatability.  They  are  the  instruments  with  which  most  of  the  treat- 
ment is  to  be  conducted.  For  these  reasons  I  have  not  used  a  bulbous 
bougie  for  many  years.  The  urethroscope  I  employ  solely  for  the  diag- 
nosis of  urethritis.  I  depend  upon  sounds  and  bougies  for  the  diagnosis 
of  stricture. 

The  sound  elicits  the  essential  diagnostic  sign  of  stricture,  viz., 


396  'IfTriiE   <>F    THL  URA 


begin  our  examination  by  passing  the  largest  sound  the  m» 
will  admit.     (Stricture  of  the  meatus  should  be  ^3).)     Thi-  i- 

gently  introduced  until  it  meets  an  obr-taele.     The  sound  is 

gently  urged  onward 

//  it  engages  in  a  stricture,  the  instrument  passes  onward  with  a 
distinct  sense  of  resistance,  while  the  patient  complains  of  more  or  less 
pain.  The  maneuver  at  this  juncture  must  be  extremely  gentle.  The 
sound  is  urged  onward  by  slight  pressure  and  is  withdrawn  if  the  sense 
of  resistance  is  extreme,  or  the  patient's  outcry  considerable.  If  the 
stricture  is  in  the  bulb,  the  unwary  operator  may  be  misled  by  the  fact 
that  he  can  depress  the  handle  of  the  sound  into  the  belief  that  its  point 
is  progressing  toward  the  bladder.  To  avoid  this  error  let  him  watch 
."  the  disappearance  of  the  shaft  within  the  meatus.  The  progress 
of  the  point  of  the  sound  is  measured  by  the  disappearance  of  its  shaft. 

But  if  the  sound,  thus  gently  introduced,  progresses  with  no  undue 
resistance  into  the  bladder,  the  true  stricture  (as  distinguished  from 
purely  inflammatory  or  spasmodic  obstruction)  grasps  the  instrument 
and  i  withdrawal.  Any  sound  that  will  thus  gently  enter  the 

unstrictured  urethra  will,  if  properly  directed,  fall  out  again  by  its  own 
weight.  But  true  stricture  grasps  the  sound,  which  can  only  be  with- 
drawn by  force.  Indeed,  the  effort  to  withdraw  the  instrument  may  be 
greater  than  that  required  to  introduce  it.  This  grasping  of  metal 
instruments  is  pathognomonic  of  stricture.  Woven  bougies  are  some- 
times, rubber  catheters  often,  grasped  by  spasm  of  the  cut-off  muscle  in 
the  unstrictured  urethra. 

If  the  sound  fails  to  engage,  smaller  instruments  are  successively  intro- 
duced until  one  enters  the  stricture.  At  or  below  15  F.  it  is  safer  to 
employ  woven  bougies  rather  than  metal  instruments,  and  with  these 
to  continue,  if  necessary,  until  a  number  10  F.  fails  to  pass.  Then  we 
know  that  either  the  stricture  is  so  small  it  will  only  admit  a  filiform 
bougie  (a  so-called  filiform  stricture),  or  else  there  is  no  stricture  at  all. 
For  no  final  diagnosis  of  stricture  can  be  made  until  an  instrument  shall 
have  passed  through  and  been  grasped  by  the  scar. 

Suggestions  of  the  presence  of  stricture  other  than  this  are  indeed 
many.  The  patient's  history  or  other  physical  signs  may  point  to 
stricture.  The  sounds  which  fail  to  pass  may  be  interrupted  before 
their  points  have  settled  well  into  the  bulbous  portion  of  the  urethra. 
The  most  gentle  manipulation  may  produce  profuse  bleeding.  Such 
signs  point  to  stricture;  but  they  do  not  infallibly  prove  its  existence. 

If  all  but  filiform  instruments  fail,  a  few  attempts  may  be  made  with 
these.  But  this  tentative  sounding  may  so  bruise  the  stricture  that 
even  a  filiform  will  not  find  its  way  in.  It  is  therefore  wiser  to  defer 
any  serious  attempt  at  passing  a  filiform  until  the  following  day.  Then 
we  may  resume  the  examination,  beginning  with  the  passage  of  filiforms. 

Some  emergencies,  e.  g.,  an  acute  retention  of  urine,  do  not  permit 
delay.  The  diagnosis  of  stricture  must  be  combined  with  the  relief  of 
retention.  Under  such  circumstances  it  may  be  wiser  to  begin  at  once 
with  filiforms,  since  these  are  so  much  more  likely  to  enter  the  stricture 


GONORRHEAL  STRICTURE  OF   THE   MALE   URETHRA       397 

if  no  previous  instrumentation  has  been  attempted.     The  manipulation 
of  filiforms  is  described  in  reference  to  treatment  (p.  400). 

After  the  diagnostic  instrumentation  the  urethra  should  be  cleansed 
with  the  routine  antiseptic  irrigation  or  instillation,  preferably  an  in- 
stillation of  1  to  1000  silver  nitrate  solution. 

The  Diagnosis  of  Impending  Stricture. — Of  even  greater  importance 
and  delicacy  than  the  diagnosis  of  existing  stricture  is  the  diagnosis 
that  stricture  is  about  to  occur.  Yet  it  is  only  by  correctly  diagnosing 
such  a  condition  that  effective  treatment  can  be  employed ;  treatment 
calculated  to  cure. 

Impending  stricture  should  be  suspected  in  every  case  of  chronic 
anterior  urethritis.  Intelligent  treatment  with  the  Kollman  dilator 
will  lead  to  the  resorption  of  those  inflammatory  exudates  that  cause 
urethritis  and  form  the  origin  of  the  scar  that  would  subsequently  form 
stricture. 

An  even  more  delicate  diagnosis  is  that  of  prospective  relapse  of  stric- 
ture in  a  strictured  urethra  that  has  been  fully  dilated.  This  topic  is 
the  most  fascinating  part  of  the  treatment  of  stricture,  and  is  there 
discussed. 

But  if  the  patient  has  been  treated  elsewhere,  and  one  does  not  feel 
sure  that  he  ever  had  a  true  stricture,  the  diagnosis  of  a  possible  recur- 
rence should  be  deferred  for  a  year.  At  the  end  of  this  interval  without 
treatment,  if  -the  urethra  readily  admits  a  full-size  sound  and  the  ure- 
throscope  shows  no  important  sclerosis  of  the  wall  of  the  canal,  the 
patient  may  safely  be  dismissed  as  free  from  the  prospect  of 
relapse. 

Treatment. — The  treatment  of  gonorrheal  stricture  may  be  preventive, 
palliative  or  curative. 

PREVENTIVE  TREATMENT. — The  preventive  treatment  of  stricture 
begins  long  before  the  stricture.  Its  foundation  is  a  discreet  management 
of  acute  gonorrhea;  for  a  gonorrhea  thus  managed  should  leave  behind 
little  or  no  trace  of  its  passage  in  the  form  of  peri-urethral  exudate. 
Just  as  the  breaking  of  chordee,  the  use  of  cauterizing  injections,  too 
much  zeal  in  the  passage  of  urethral  instruments,  etc.,  are  causes  of 
gonorrheal  exacerbations  and  complications,  so  gentleness  and  dis- 
cretion eliminate  these  causes  and  prevent  stricture. 

Once  chronic  anterior  urethritis  has  been  established,  the  treatment 
of  this,  and  especially  the  treatment  with  the  Kollman  dilator,  is  cal- 
culated to  cause  resorption  of  the  exudate  before  it  forms  the  dense 
peri-urethral  scar  which  we  call  stricture.  For  even  though  the  founda- 
tions of  this  scar  are  laid  down  by  acute  attacks  of  gonorrhea,  the  scar 
itself  may  be  very  slow  to  form,  and  still  slower  to  show  any  perceptible 
tendency  to  contract. 

PALLIATIVE  TREATMENT. — The  palliative  treatment  of  urethral  stric- 
ture consists  in  dilatation.  From  what  has  been  said  in  discussing  the 
progress  of  stricture,  it  will  be  readily  understood  that  dilatation  may 
occasionally  cure  a  stricture.  But,  the  prime  object  of  dilatation  is  to 
control  stricture,  not  to  cure  it.  No  amount  of  stretching  can  banish 


398  STRICTURE  OF   THE   URETHRA 

a  scar  from  the  urethral  wall.  So  long  as  the  scar  is  there  it  is  likely  to 
recontract.  The  physician,  therefore,  will  be  well  advised  to  consider 
his  dilatation  purely  palliative. 

Antisepsis  and  Anesthesia. — The  most  rigorous  asepsis  of  instru- 
ments, patient's  urethra  and  physician's  hands  should  be  practised  as  a 
matter  of  routine.  But,  inasmuch  as  the  patient's  urethra  cannot  be 
cleansed  of  the  bacteria  that  lurk  within  its  glands,  the  two  essential 
elements  to  prevent  complications  are : 

1.  Extreme  gentleness  in  the  passage  of  all  urethral  instruments, 
whereby  the  urethral  wall  is  spared  and  the  foci  of  infection  within  are 
not  stimulated  to  activity. 

2.  Antisepsis;  preferably  by  an  instillation  of  silver  nitrate  (1  to 
1000)  after  the  passage  of  instruments.    This  may  often  be  properly 
supported  by  the  administration  of  hexamethylenamin,  1  gm.  twice  or 
three  times  a  day,  for  two  days  preceding  the  operation. 

The  anesthesia  produced  by  filling  the  anterior  urethra  with  1 
per  cent,  novocain  for  15  minutes  before  the  passage  of  instruments 
may  be  employed  for  each  dilatation.  But,  though  this  is  extremely 
useful  to  gain  the  patient's  confidence  for  the  first  dilatation,  its  routine 
use  tends  to  encourage  brutality  in  the  passage  of  instruments  into  the 
urethra  and  is  rather  to  be  discouraged.  It  is  usually  quite  possible 
after  a  few  treatments  to  proceed  with  dilatation  without  any  local 
anesthetic.  Indeed,  the  patient  may  not  note  the  omission. 

DILATATION.— Instruments  Required. — A  complete  equipment  of  dilat- 
ing instruments  includes  filiform  bougies  and  followers,  woven  bougies, 
conical  sounds  and  dilators. 

Filiforms  and  Followers. — The  filiform  bougie  should  have  a  smooth, 
rounded,  olivary  point  and  a  flexible  neck,  which  can  be  temporarily 
bent  at  any  required  angle.  One  should  possess  instruments  whose  tips 
vary  considerably  in  size. 

Filiforms  are  made  in  two  types.  The  one,  a  whalebone  instrument 
to  be  used  with  a  tunnelled  sound  or  catheter;  the  other,  a  woven 
instrument,  to  the  butt  end  of  which  is  affixed  a  screw,  whereby  it  can 
be  screwed  to  a  following  sound  or  catheter.  I  much  prefer  the  latter 
type.  It  has  a  more  flexible  point  which  can  be  set  at  an  angle  by  a 
drop  of  collodion.  Its  screw  junction  with  the  following  instrument  is, 
of  course,  much  smoother  than  that  of  the  whalebone-tunnelled 
combination.  But  the  woven  instruments  are  relatively  destructible, 
and  can,  therefore,  not  be  employed  in  hospitals  or  dispensaries  under 
ordinary  circumstances. 

Filiforms  are  sometimes  made  with  their  points  set  in  curious  cork- 
screw shapes;  these  have  no  advantage.  The  point  of  the  filiform 
should  be  a  little  offset  from  its  centre;  so  that,  after  it  has  been  intro- 
duced as  far  as  the  face  of  the  stricture,  it  may  be  revolved  to  make  its 
point  search  over  a  limited  area  for  the  orifice.  Any  complicated 
angulation  is  wasted. 

The  followers  for  whalebone  filiforms  are  made  of  metal.  The  screw 
instruments  for  the  woven  filiforms  are  themselves  woven.  A  complete 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       399 

set  runs  from  10  to  20  F.     One  should  possess  catheters,  as  well  as 
sounds,  of  this  description. 

Woven  Bougies. — With  the  filiform  and  its  followers  the  stricture  can 
be  conveniently  dilated  to  10,  15  or  even  20  F.,  though  it  is  preferable 
to  use  woven  olivary-tipped  bougies,  after  the  first  passage  of  filiform 
and  follower.  A  set  of  bougies  runs  from  10  to  22  F.  Bougies  weighted 
with  shot,  or  with  a  lead  core,  are  rather  preferable;  since  their  weight 
makes  them  dilate  the  stricture  somewhat  more  forcefully. 

Sounds. — When  skilfully  manipulated,  the  conical  steel  sound  ac- 
tually causes  less  pain  than  the  woven  bougie.  But  the  sharp  point  of 
a  small-sized  sound  is  so  likely  to  catch  in  the  urethral  wall  that,  as  a 
general  rule,  one  employs  woven  instruments  up  to  size  20  F.,  and  sounds 
from  this  point  to  the  limit  of  the  meatus.  I  rarely  employ  a  sound 
larger  than  29  F. 

On  the  other  hand,  the  fixed  curve  of  a  steel  sound  makes  it  an  ad- 
mirable instrument  for  entering  the  orifice  of  a  tight  stricture  in  the 
bulbous  urethra.  I  have  not  unfrequently  entered  a  stricture  with  the 
10  or  12  F.  steel  sound,  the  orifice  of  which  I  could  not  locate  with  the 
filiform.  But  the  maneuver  is  so  difficult  that  it  should  only  be 
attempted  by  the  skilled  practitioner;  the  uninitiated  will  inevitably 
drive  the  sharp  point  of  a  small  sound  into  the  urethral  wall. 

Dilators. — For  sizes  larger  than  the  meatus  will  admit,  the  dilator 
should  be  employed.  All  modern  dilators  are  modifications  of  the 
Kollman  instrument.  I  have  never  employed  an  instrument  with  an 
irrigating  attachment,  or  one  that  dilates  only  a  portion  of  the  urethra. 
The  model  I  employ  has  a  Benique  curve,  and  is  made  to  dilate  the 
whole  urethra.  Here,  again,  I  differ  from  the  opinion  of  those  who 
consider  that  precise  treatment  requires  dilatation  of  only  the  strictured 
point.  I  despair  of  such  precise  diagnosis.  The  strictured  urethra  is 
likely  to  be  chronically  inflamed  throughout.  The  more  fully  it  is 
dilated  the  better. 

Dilatation  of  Strictures  at  the  Meatus. — It  is  a  waste  of  time  to  attempt 
dilatation  of  strictures  of  the  terminal  inch  of  the  urethra.  They 
should  be  cut  (p.  403). 

Dilatation  of  the  Pendulous  and  Scrotal  Portions. — Strictures  in  this 
region  may  be  dilated  if  they  have  existed  for  a  relatively  brief  period. 
But,  as  a  rule,  they  do  not  yield  to  dilatation. 

Under  such  circumstances  they  should  be  subjected  to  internal 
urethrotomy,  as  described  below. 

Strictures  of  the  Bulbous  and  Membranous  Urethra. — These,  the  most 
common  of  gonorrheal  strictures,  yield  most  admirably  to  dilatation. 
Unless  complicated  by  trauma  or  peri-urethritis  they  can,  as  a  rule,  be 
controlled  for  an  indefinite  period  by  the  intelligent  passage  of  sounds. 
Yet  even  here  urethrotomy  is  called  for  when  dilatation  fails. 

The  Technic  of  Dilatation. — Let  us  suppose  a  stricture  in  the  bulbous 
urethra  that  will  admit  only  a  filiform  instrument.  By  describing  the 
series  of  treatments  whereby  this  is  fully  dilated  we  shall  cover  the  whole 
ground. 


400  STRICTURE  OF   THE   URETHRA 

The  diagnosis  has  been  established  by  vain  attempts  to  pass  larger 
instruments.  We  now  resort  to  filiforms. 

After  the  preliminary  asepsis  and  anesthesia  we  select  a  filiform,  bend 
its  tip  a  little  eccentrically,  and  introduce  it  slowly  into  the  urethra.  It 
catches  here  and  there,  whereupon  we  withdraw  it,  rotate  the  point  to 
one  side,  and  so  pass  the  obstacle.  If  we  are  fortunate  the  filiform 
passes  the  stricture  readily,  but  usually  it  is  obstructed.  It  will  not 
engage  in  the  stricture.  Then  it  must  be  patiently  and  gently  moved 
up  and  down,  turning  the  point  now  to  the  right,  now  to  the  left,  but 
searching  for  the  orifice-  of  the  stricture  rather  toward  the  roof  of  the 
urethra  than  toward  its  floor.  If  the  point  of  the  filiform  finally  slips 
into  the  stricture,  it  may  be  obstructed  by  catching  in  the  utricle  or 
some  pocket  of  the  posterior  urethra.  That  the  filiform  has  passed  the 
stricture  is  recognized  by  estimating  the  depth  to  which  it  has  pene- 
trated in  the  urethra.  That  it  is  caught  in  the  posterior  urethra  is  veri- 
fied by  a  finger  in  the  rectum  pressing  against  the  membranous  urethra. 
The  filiform  is  gently  moved  to  and  fro  until  the  pressure  of  the  finger 
makes  it  ride  out  of  this  obstacle  and  into  the  bladder.  Then  the  fol- 
lower is  screwed  or  slipped  onto  the  filiform  and  gently  pushed  into  the 
bladder. 

The  filiform  is  not  so  sure  a  guide  as  might  be  imagined;  it  will 
buckle,  and  even  break,  if  the  follower  is  pushed  in  with  too  great  haste. 
The  size  of  the  follower  should  vary  with  the  age  and  density  of  the 
stricture.  If  the  stricture  is  thought  to  be  but  a  single  band,  and  the 
scar  so  slight  that  no  definite  irregularity  can  be  felt  in  the  perineum 
at  the  point  of  stricture,  one  may  sometimes  advantageously  employ  a 
follower  as  large  as  14  or  16  F.  But  if  the  scar  is  an  ancient  indurated 
mass,  the  first  instrument  passed  should  be  no  larger  than  a  10  F.,  and 
it  is  often  wiser  to  attempt  no  further  dilatation  until  several  days  later. 

The  operation  is  followed  by  the  customary  instillation  of  silver 
nitrate,  the  instillator  being  placed  as  accurately  as  possible,  in  the 
hope  that  some  of  the  solution  may  pass  into  the  posterior  urethra.  • 

//  the  filiform  fails  to  enter  the  stricture,  several  alternatives  present 
themselves:  The  instrument  may  be  withdrawn  and  tried  again,  after  a 
different  angle  has  been  given  to  its  point;  or  filiforms  with  larger  or 
smaller  bulbs  may  be  tried ;  or  one  may  fill  the  urethra  with  filiforms, 
and  push  in  first  one  and  then  another,  in  the  hope  that  one  of  them 
may  enter  the  stricture. 

If  these  maneuvers  fail,  and  if  the  stricture  is  a  relatively  narrow  band 
down  to  the  face  of  which  a  urethroscope  can  be  introduced,  one  may 
attempt  the  passage  of  filiforms  through  the  urethroscope  guided  by  the 
eye.  Young  speaks  highly  of  this  procedure,  but  I  have  had  no  success 
with  it. 

In  quite  a  number  of  instances,  having  failed  to  introduce  a  filiform,  I 
have  succeeded  in  passing  a  10  F.  steel  sound  (with  the  Van  Buren 
curve) ;  but  this  instrument  must  be  employed  with  the  greatest  imagin- 
able gentleness,  otherwise  the  sharp  point  of  the  sound  will  perforate 
the  scar  and  produce  a  false  passage. 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       401 

Even  after  failing  with  all  instruments,  the  operation  should  be 
followed  by  an  instillation  of  silver  nitrate  against  the  face  of  the 
stricture.  If  no  complications  ensue,  the  gentle  attempt  to  pass 
instruments  may  be  repeated  day  after  day  for  several  days,  until  the 
patient's  and  operator's  patience  are  exhausted.  But  the  appearance 
of  any  complication,  such  as  fever,  retention,  or  peri-urethritis,  calls 
for  immediate  operation. 

In  the  absence  of  such  complications  there  is  no  limit  to  the  number 
of  attempts  that  may  be  made  to  pass  a  stricture  with  filiform,  but  it  is 
probable  that  the  patient's  interests  will  be  best  served  by  prompt 
operation  after  the  failure  of  two  or  three  attempts  at  instrumen- 
tation. 

But  before  this  final  decision  is  reached  the  physician  should  once 
again  try  to  pass  a  20  F.  sound  into  the  stricture  to  be  sure  that,  after 
all,  this  cannot  pass.  Thereby  he  will  be  saved  the  mortification  later 
of  passing  a  sound  after  the  anesthetic  has  been  administered. 

When  a  filiform  finally  has  been  passed,  after  many  fruitless  efforts, 
one  is  tempted  to  tie  it  in  to  act  as  a  guide  for  further  dilatation.  There 
is  no  objection  to  this,  but  unless  the  stricture  is  particularly  compli- 
cated, or  unless  all  followers  have  failed  to  pass,  the  tying  in  of  a  filiform 
is  a  waste  of  time. 

Subsequent  Dilatation. — If  the  stricture  has  been  satisfactorily  di- 
lated by  filiforms  and  followers,  no  further  attempt  at  instrumentation 
should  be  made  (unless  retention  demands  it)  until  the  fourth  or  fifth 
day;  then  the  same  procedure  as  before  should  be  followed,  the  first 
instrument  used  being  chosen  with  relation  to  previous  experience.  At 
this  second  instrumentation  it  is  prudent  not  to  attempt  to  dilate  the 
stricture  much  wider  than  at  the  preceding  sitting.  Thus,  if  the  first 
dilatation  was  to  10  or  12  F.,  10  or  12  F.  may  again  suffice,  for  the  object 
of  dilatation  of  a  very  tight  stricture  is  to  iron  out  its  irregularities 
rather  than  to  dilate  it  rapidly.  By  the  third  or  fourth  treatment  these 
irregularities  are  usually  sufficiently  smooth  to  permit  dilatation  to 
proceed  more  rapidly. 

The  ideal  interval  is  from  five  to  seven  days,  for  time  must  be  given 
to  the  surface  of  a  stricture  to  recover  from  the  trauma  of  one  instru- 
mentation before  a  second  is  attempted.  The  rapidity  of  dilatation  is, 
of  course,  never  twice  the  same;  but  if  the  stricture  yields  rapidly,  one 
need  not  fear  to  advance  as  much  as  five  to  ten  numbers  on  any  one 
occasion.  Each  sitting  is  begun  with  the  passage  of  an  instrument  at 
least  one  or  two  sizes  smaller  than  the  largest  instrument  that  has  been 
passed.  If  this  fails  to  enter  one  may  have  to  return  to  the  smaller 
instrument — to  begin  all  over  again,  as  it  were.  If  it  enters  and  is 
rather  tightly  grasped  the  next  sound  to  be  passed  should  be  but  one 
size  larger.  But  if  the  first  instrument  is  not  tightly  grasped,  one  may 
skip  several  sizes,  sometimes  three  or  four,  writh  advantage.  It  is  much 
wiser  not  to  pass  more  than  three  sounds  on  any  one  day.  These  should 
be  passed  with  the  utmost  gentleness ;  and  while  it  is  not  quite  true  that 
they  should  enter  by  their  own  weight,  they  should  very  nearly  do  this. 

M  U     I — 26 


402  STRICTURE  OF  THE   URETHRA 

There  is  no  advantage  in  leaving  the  sound  within  the  grasp  of  the 
stricture  for  more  than  a  moment.  Each  treatment  is  concluded  with 
an  instillation  of  silver  nitrate. 

Bougies  are  used  up  to  about  20  F. ;  sounds  to  the  limit  of  the  meatus; 
dilators  to  the  full  size,  which  should  be  30  F.  or  a  little  higher. 

After  the  stricture  has  been  so  dilated  that  the  dilator  enters  readily 
and  can  be  screwed  up  to  30  or  32  F.  without  being  tightly  grasped  or 
without  exciting  hemorrhage,  the  interval  between  instrumentation  is 
lengthened  from  one  to  two  weeks;  then  to  a  month;  to  three;  to  six 
months  on  condition  that  the  stricture  shows  no  tendency  to  recontract. 
Thereafter  the  dilator  must  be  introduced  to  celebrate  New  Year's  day 
and  the  Fourth  of  July  for  the  rest  of  the  patient's  life,  if  the  stricture 
is  in  the  bulb. 

The  more  intelligent  type  of  patient  may  be  instructed  how  to  boil 
his  sound  and  to  wash  his  hands  and  penis  and  to  introduce  a  full-sized 
sound.  Although  there  is  less  danger  of  urethral  chill  following  the 
gentle  and  cleaner  passage  of  a  sound  by  a  surgeon,  if  that  instrumenta- 
tion be  followed  by  the  instillation  of  silver  nitrate  along  the  urethra, 
yet  it  is  so  contrary  to  human  nature  for  any  man  to  return  year  after 
year  for  treatment,  that  it  seems  fair  in  many  instances  to  entrust  the 
sound  to  the  patient.  If  at  any  time  he  fails  to  introduce  the  instru- 
ment he  must,  of  course,  appeal  for  professional  aid. 

Operative  Treatment  of  Stricture. — Indications  for  Operation. — The 
failure  of  dilatation  is  the  only  excuse  for  operation  upon  urethral 
stricture.  This  failure  may  be  of  several  kinds.  Thus  stricture  of  the 
meatus  can  never  be  dilated;  we  know  beforehand  that  dilatation  will 
fail  and  we  operate  accordingly. 

Stricture  of  the  pendulous  urethra  is  amenable  to  dilatation  only 
when  the  scar  has  not  become  fully  organized.  Tight  stricture,  or 
dense  stricture,  or  stricture  that  is  palpable,  as  a  thickness  of  the  corpus 
spongiosum  in  the  pendulous  urethra,  may  be  dilated  up  to  a  certain 
point,  but  must  be  cut  in  order  to  be  cured. 

Stricture  of  the  bulbous  urethra,  on  the  other  hand,  if  of  gonorrheal 
origin  and  not  complicated  by  retention  or  peri-urethritis,  may  usually 
be  controlled  by  dilatation.  But  if  the  stricture  cannot  be  dilated,  or 
if  it  persistently  relapses  in  spite  of  intelligent  treatment,  or  if  retention 
or  infection  of  kidney,  prostate,  or  peri-urethral  tissue  require  drainage, 
which  dilatation  does  not  afford,  then  operation  (external  urethrotomy) 
is  indicated. 

It  is  the  part  of  wisdom  to  err  on  the  side  of  operating  too  early 
rather  than  too  late.  Peri-urethritis  always  requires  operation,  and  a 
stricture  that  remains  impassable  or  proves  rebellious  in  the  course  of 
dilatation  should  be  operated  upon  as  soon  as  the  patient's  consent 
can  be  obtained. 

Choice  of  Operation. — For  strictures  of  the  meatus,  meatotomy.  For 
strictures  of  the  pendulous  and  scrotal  urethra,  internal  urethrotomy 
upon  the  roof  of  the  canal.  For  strictures  of  the  bulbous  urethra, 
external  urethrotomy. 


Choice  of  Anesthetic. — For  meatotomy  or  internal  urethrotomy  local 
anesthesia  suffices  after  a  preliminary  hypodermic  injection  of  morphin. 
A  solution  of  1  per  cent,  novocain,  containing  1  drop  of  adrenalin 
(1  to  1000)  to  every  2  c.c.  of  solution,  is  injected  into  the  anterior 
urethra  and  there  retained  for  twenty  minutes.  This  gives  ample 
anesthesia  for  any  internal  urethrotomy. 

The  choice  of  anesthetic  for  external  urethrotomy  is  still  a  subject  of 
much  discussion.  The  basis  of  the  discussion  is  the  difficulty  of  de- 
termining (by  phenolsulphonephthalein  or  any  other  test)  the  precise 
condition  of  the  patient's  kidneys.  The  stricture  that  requires  opera- 
tion is  usually  an  ancient  one  and  may  have  impaired  the  kidney 
function  far  more  than  is  suspected.  For  this  reason  perineal  section, 
casually  performed,  has  an  extremely  high  mortality.  But  if  the  danger 
of  renal  death  is  borne  in  mind  and  the  patient  with  urethral  stricture 
submitted  to  the  same  careful  examination  and  preliminary  treatment 
as  is  the  candidate  for  prostatectomy,  the  question  of  anesthetic  will  be 
solved  along  similar  lines.  Local  anesthesia  by  means  of  novocain  and 
adrenalin  within  the  urethra,  as  for  internal  urethrotomy,  aided  by 
massive  infiltration  of  the  perineum  behind  the  point  of  operation  with 
0.25  per  cent,  novocain  (and  adrenalin)  solution,  covers  the  field  except- 
ing only  the  posterior  urethra  and  bladder  neck.  But  the  sensitiveness 
of  these  is  impaired  and  does  not  occasion  either  operator  or  patient 
any  grave  inconvenience. 

I  have  also  employed  sacral  anesthesia  with  varied  success,  and  spinal 
anesthesia  in  many  instances  with  no  mishaps.5 

Gas  and  oxygen  is  the  anesthetic  of  choice  in  many  instances;  peri- 
sacral  anesthesia  I  have  not  employed. 

MEATOTOMY. — The  straight,  blunt-pointed  bistoury  is  the  best  instru- 
ment with  which  to  cut  the  meatus.  We  need  also  several  sounds  to 
measure  the  resulting  caliber  of  the  urethra. 

The  end  of  the  patient's  penis  is  washed  with  soap  and  water,  the  field 
of  operation  anesthetized  by  inserting  a  piece  of  cotton  soaked  in  1 
per  cent,  novocain  (adrenalin)  solution.  After  this  has  been  in  place 
twenty  minutes  it  is  removed,  the  bistoury  inserted  into  the  urethra, 
well  within  the  second  meatus,  the  head  of  the  penis  compressed  very 
tightly  from  side  to  side,  and  the  knife  quickly  withdrawn,  cutting  the 
floor  of  the  urethra  to  the  required  depth.  Only  the  experienced  opera- 
tor can  expect  to  achieve  the  desired  result  with  a  single  stroke  of  the 
knife.  The  tyro  should  cut  too  little  rather  than  too  much,  and  should 
remember  that  the  internal  meatus  at  the  depth  of  about  1  cm.  is  often 
tighter  than  the  orifice  itself.  A  28  or  30  F.  sound  is  immediately 
introduced.  If  this  will  not  pass  readily,  further  cutting  is  re- 
quired. 

If  adrenalin  has  been  employed  the  after-bleeding  is  usually  slight. 
No  suture  or  cauterization  of  the  wound  is  worth  considering.  But 
gentle  lateral  compression  should  be  made  until  the  bleeding  stops. 
Then  a  large  dressing  should  be  applied  with  a  penis  bag  and  the  penis 
held  against  the  groin  with  a  jock-strap  or  bandage.  The  patient  is 


404  STRICTURE  OF   THE   URETHRA 

instructed  how  to  remove  his  bandage  before  urinating,  and  how  to  stop 
bleeding  by  lateral  compression  of  the  glans  penis.  He  is  seen  daily  and 
the  wound  kept  open  by  the  passage  of  a  probe.  Xo  further  attempt  to 
pass  a  sound  should  be  made  until  a  week  has  passed,  and  thereafter  a 
sound  about  two  sizes  smaller  than  the  one  originally  passed  should  be 
introduced  often  enough  to  keep  the  urethra  open  until  it  has  healed ; 
this  always  requires  at  least  two  weeks. 

Complications. — I  have  never  seen  any  complications  other  than 
bleeding  follow  meatotomy.  The  control  of  the  bleeding  may  be  en- 
trusted to  the  patient  himself  unless  his  mental  or  social  circumstances 
are  such  that  it  seems  wiser  to  make  the  operation  a  formal  one  and  keep 
him  in  bed  for  a  day  or  two  under  the  care  of  a  nurse. 

IXTERXAL  URETHROTOMY.— Instruments  Required. — Of  the  many 
types  of  urethrotomes  the  Otis  is  the  best  suited  for  those  strictures 
that  will  admit  it,  while  tighter  strictures  may  be  cut  by  the  Maison- 
neuve.  Appropriate  sounds  to  measure  the  resulting  urethral  caliber 
and  an  indwelling  catheter  may  be  needed. 

The  Operation. — The  operation  may  be  performed  under  local  anes- 
thesia as  described  above.  It  is,  however,  unsafe  to  perform  it  in  the 
office.  The  patient  should  be  at  his  home  or  in  a  hospital. 

Inasmuch  as  the  urethra  is  inevitably  infected  and  this  infection  lies 
largely  beneath  its  surface,  gentle  irrigation  of  the  anterior  urethra  to 
cleanse  it  of  gross  pus,  and  soap  and  water  wash  to  the  penis,  fulfil  the 
requirements  of  asepsis  of  the  patient's  person.  Asepsis  of  instruments, 
operator  and  operating  field  is  carried  out  as  for  a  major  operation. 

The  stricture  or  strictures  have  been  previously  located  and  cali- 
brated. 

In  almost  every  instance  the  Otis  urethrotome  may  be  introduced. 
It  is  passed  into  the  grip  of  the  stricture  and  about  2  cm.  farther,  its 
knife  pointed  toward  the  roof  of  the  canal.  This  places  the  dial  in  a 
very  inconvenient  position,  yet  it  ensures  against  cutting  too  deeply  ofr, 
a  deep  cut  on  the  roof  merely  enters  the  septum  between  the  corpora 
cavernosa,  while  a  similar  violation  of  the  floor  or  sides  of  the  canal 
would  open  the  peri-urethral  cellular  tissue  and  result  in  abscess.  The 
urethrotome  is  now  screwed  up  to  about  35  F.  and  the  knife  slowly 
withdrawn  until  it  is  felt  to  jump  through  the  strictured  portion  of  the 
urethra.  The  urethrotome  is  then  immediately  screwed  down  to  its 
smallest  size  and  withdrawn.  A  30  or  31  F.  sound  is  passed  to  the 
bulbous  urethra,  but  no  farther. 

If  at  the  first  attempt  one  deems  it  unwise  to  screw  the  urethrotome 
all  the  way  up  to  35,  or  if  after  the  cutting  the  sound  does  not  pass  freely, 
a  second  cut  upon  the  roof  may  be  made.  The  meatus  may  be  cut  by 
turning  the  instrument  over  and  cutting  on  the  floor  at  this  point.  If 
after  the  division  of  the  first  stricture  other  unsuspected  points  of 
constriction  are  found,  these  must  be  cut.  During  this  whole  operation 
no  instrument  has  been  introduced  into  the  membranous  urethra. 

The  surgeon  now  estimates  the  amount  of  bleeding.  If  this  is  slight 
no  dressing  is  required  other  than  a  hood  of  gauze  to  keep  the  bed -covers 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       405 

clean.  The  patient  is  left  to  urinate  at  will,  with  the  assurance  that 
since  nothing  has  been  introduced  into  the  posterior  urethra,  urethral 
chill  will  not  occur. 

But  if  the  bleeding  following  the  operation  is  severe  it  is  wiser  to  tie  a 
catheter  into  the  bladder:  the  mere  presence  of  this  instrument  stays 
the  hemorrhage  in  almost  every  instance.  Any  bleeding  that  persists 
may  be  controlled  by  pressure.  But  if  much  pressure  is  required  it  is 
wiser  to  adjust  small  splints  to  the  dorsum  and  the  venter  of  the  penis, 
making  pressure  upon  these,  so  that  the  penis  will  not  be  strangled  in 
case  of  erection.  This  indwelling  catheter  should  remain  in  place  two 
to  four  days. 

Complications. — The  precaution  alluded  to  excludes  any  danger  from 
urethral  chill  or  any  other  forms  of  urinary  infection.  The  method  of 
controlling  hemorrhage  has  been  described.  Peri-urethritis  as  a  result 
of  overcutting  I  have  not  seen.  Among  over  150  operations  reported  in 
our  case-books  there  was  1  death  from  pyemia. 

If  the  stricture  is  too  small  to  admit  the  Otis  instrument  the  Maison- 
neuve  may  be  employed.  If  it  is  impassable,  perineal  section  is  per- 
formed and  the  urethrotome  passed  from  behind  forward. 

After-treatment. — If  the  indwelling  catheter  is  used  this  is  withdrawn 
on  the  second,  third,  or  fourth  day.  Thereafter  the  patient  goes  about 
his  business  as  usual.  The  first  sound  is  passed  between  the  tenth  and 
the  fourteenth  day.  It  is  well  to  begin  with  a  woven  bougie  of  about 
16  or  18  F.  size.  This  gently  dilates  the  urethral  wound  and  may  be 
followed  by  a  24  or  25  F.  bougie  or  sound.  No  attempt  is  made  to 
pass  a  larger  instrument  at  the  first  sitting. 

Thereafter  the  patient  returns  for  instrumentation  every  five  days, 
and  as  soon  as  the  stricture  can  be  dilated  to  25  F.  without  considerable 
bleeding,  further  dilatation  up  to  30  F.  is  carried  on  with  the  Kollmann 
dilator.  As  soon  as  the  full  size  is  reached  without  causing  considerable 
hemorrhage  the  interval  between  sittings  is  increased  to  two  weeks,  and 
dilatations  are  continued  at  this  interval  until  the  wound  is  healed  and 
the  urethritis  controlled.  This  will  usually  take  about  three  months. 
The  patient  is  then  requested  to  return  after  an  interval  of  six  months. 
If  at  the  end  of  this  time  the  urethritis  has  not  relapsed  and  the  stricture 
has  not  recontracted,  he  may  be  dismissed  as  cured;  otherwise  he  may 
require  further  dilatation  or  cutting. 

EXTERNAL  URETHROTOMY  WITH  A  GUIDE. — Instruments  Required. — 
In  addition  to  the  usual  instruments,  external  urethrotomy  requires  a 
curved,  sharp-pointed  bistoury,  a  female  catheter  (preferably  of  metal), 
two  or  three  grooved  staffs  of  different  sizes,  or  if  the  stricture  is  known 
to  be  too  small  to  admit  these,  filiforms  and  tunnelled  followers.  The 
groove  of  all  staffs  and  followers  should  be  as  wide  as  possible,  so  that 
the  knife  plunged  into  the  perineum  may  readily  find  it.  The  familiar 
soft-rubber  perineal  tube  with  a  lateral  as  well  as  a  terminal  eye  is 
usually  employed  for  drainage  after  the  operation;  but  one  should  have 
at  hand  a  double-current  tube  for  continuous  irrigation  in  case  the 
bladder  neck  is  so  torn  as  to  bleed  alarmingly. 


406  STRICTURE  or   THE   URETHRA 

The  Operation. — The  operation  performed  by  the  expert  when  the 
stricture  is  of  sufficient  caliber  to  admit  a  grooved  staff  is  quite  different 
from  that  employed  for  a  tighter  stricture  or  by  a  less  experienced 
operator. 

The  Operator  is  Expert:  The  Stricture  Admits  a  Sta/. — The  patient  is 
placed  in  the  lithotomy  position,  i.  e.,  with  the  buttocks  brought  down 
so  that  they  overhang  the  edge  of  the  table  and  both  hips  and  knees 
sharply  flexed  and  supported  by  some  form  of  stirrup.  If  the  table  is 
low  the  operator's  comfort  requires  that  the  patient's  buttocks  be 
elevated  on  a  sand  bag. 

The  usual  asepsis  is  employed. 

A  grooved  staff  is  introduced  into  the  urethra  and  passed  into  the 
stricture  and  well  into  the  bladder  (to  prove  that  the  instrument  is  not 
in  a  false  passage) .  It  is  then  partially  withdrawn  and  passed  to  an 
assistant,  who  holds  it  in  such  a  position  that  its  groove  projects  in  the 
median  line  of  the  perineum  so  as  to  be  readily  palpable.  With  his 
other  hand  this  assistant  pulls  the  scrotum  up  out  of  the  operator's  way. 
The  operation  is  now  performed  with  a  single  thrust  of  the  knife.  The 
curved,  sharp-pointed  bistoury  is  plunged  through  the  perineum  into 
the  groove  of  the  staff  at  a  point  about  4  cm.  in  front  of  the  anus,  where 
the  staff  begins  to  curve  away  from  the  perineum  up  toward  the  mem- 
branous urethra.  The  point  of  the  knife  is  then  carried  backward  in 
the  groove  of  the  staff  for  1  or  2  cm.  until  it  just  enters  the  membranous 
urethra;  then  with  a  downward  stroke  its  point  is  withdrawn  so  as  to 
cut  a  hole  through  the  urethra,  the  perineum  and  the  skin  quite  large 
enough  to  admit  the  finger  readily.  Some  practise  is  required  to  per- 
form this  stroke  accurately.  It  is  essential  that  the  mucosa  of  the 
urethra  be  widely  incised. 

As  soon  as  the  knife  is  withdrawn  the  operator  introduces  his  fore- 
finger, feels  for  the  groove  of  the  staff,  and  makes  sure  that  his  finger 
rests  against  this  with  no  mucous  membrane  between.  Then  taking 
the  handle  of  the  staff  in  his  left  hand  he  slowly  withdraws  this  while 
pressing  quite  firmly  against  the  groove  with  his  finger  in  the  wound. 
As  the  tip  of  the  staff  slips  from  beneath  this  finger  it  feels  the  roof  of 
the  canal  and  follows  this  backward  into  the  membranous  urethra  and 
thence  into  the  bladder.  If  the  deeper  portion  of  the  stricture  has  not 
been  sufficiently  incised  at  the  first  stroke  of  the  knife  a  grooved  director 
may  be  introduced  through  the  perineum  and  the  floor  of  the  urethra 
sufficiently  divided  with  a  scalpel  to  admit  the  tip  of  the  finger,  after 
which  the  remaining  fibers  are  torn.  The  finger  as  it  enters  notices  the 
presence  or  absence  of  any  prostatic  areas  suggestive  of  stone,  abscess, 
etc.,  and  on  withdrawal  it  sweeps  the  roof  of  the  urethra  to  be  sure  there 
is  no  projecting  band  of  stricture  there.  If  such  a  band  is  found  it  is 
nicked  or  cut  away. 

A  30  F.  sound  is  then  introduced  into  the  meatus  and  passed  into  the 
bladder.  If  this  is  obstructed,  meatotomy  or  internal  urethrotomy  are 
performed  as  required. 

The  rubber  perineal  tube  is  then  grasped  by  a  long  forceps  in  such  a 


GONORRHEAL  STRICTURE  OF  THE  MALE  URETHRA       407 

way  as  to  bend  its  tip  like  an  elbowed  catheter.  It  is  thus  readily 
introduced  into  the  bladder,  the  forceps  withdrawn,  and  a  syringeful  of 
1  to  5000  silver-nitrate  solution  washed  through  the  tube  to  make  sure 
that  it  is  in  proper  position.  If  the  fluid  fails  to  return,  this  may  be 
either  because  the  tube  is  too  far  in  or  not  far  enough  in,  or  because  its 
eye  is  obstructed  by  clots.  Clots  may  be  aspirated  with  the  piston 
syringe.  The  proper  position  of  the  tube  will  be  assured  if  the  operator 
is  careful  to  insert  into  the  wound  a  length  only  a  little  more  than  that  of 
his  own  forefinger. 

After  the  tube  has  been  properly  placed  it  is  held  in  by  a  catgut 
suture  that  catches  the  two  edges  of  the  wound  and  is  wound  four  or  five 
times  around  the  tube  (pins  or  needles  stuck  through  the  tube  soon 
destroy  it) . 

The  patient's  legs  are  then  let  down,  a  thick  dressing  applied  under 
a  T-bandage,  the  testicles  being  well  supported  by  this;  the  patient  is 
then  removed  from  the  table  to  his  bed,  and  after  reaching  his  bed  the 
proper  function  of  the  tube  is  again  tested.  After  this  a  large  rubber 
tube  is  attached,  leading  over  the  side  of  the  bed  into  a  bottle. 

Precautions. — Experience  and  skill  are  required  to  perform  the  opera- 
tion in  this  manner.  The  tyro  by  making  his  first  incision  wrong  is 
likely  never  to  get  his  finger  into  the  urethra,  but  will  burrow  with  it 
outside  of  the  mucosa  which  lies  between  him  and  the  staff.  Then  on 
withdrawing  the  staff  and  realizing  that  he  is  lost  he  will  fail  to  reinsert 
his  guide,  then  he  will  cut  through  the  roof  of  the  urethra  and  never 
reach  the  bladder. 

A  precaution  to  be  applied  to  every  form  of  external  urethrotomy  is 
not  to  pack  the  urethra  around  the  tube.  The  immediate  profuse 
bleeding  promptly  ceases;  or  may  be  controlled  by  firm  pressure  of  the 
external  dressing  against  the  tube.  Packing  about  the  tube  is  likely  to 
excite  much  more  hemorrhage,  when  it  is  removed  a  few  days  later, 
than  would  have  occurred  in  the  first  place.  Furthermore,  it  encourages 
infection  and  delays  healing. 

Some  operators  prefer  to  apply  an  indwelling  catheter  and  sew  the 
urethra  rather  closely  about  this,  while  leaving  the  skin  of  the  perineum 
open.  But  I  believe  the  wound  heals  better  if  a  straight  perineal  sinus 
remains  as  left  by  the  perineal  tube. 

After-treatment. — If  there  is  any  grave  question  of  the  kidney  func- 
tion this  is  stimulated  as  after  prostatectomy  by  injection  of  salt  solu- 
tion through  the  rectum,  forcing  fluids  by  mouth,  and  fresh  air.  The 
perineal  tube  is  usually  removed  at  the  end  of  twenty-four  to  forty-eight 
hours,  but  doubtful  renal  function  may  encourage  longer  drainage.  In 
this  event  it  is  wise  to  replace  the  large  tube  by  a  smaller  one,  either  in 
the  perineum  or  through  the  anterior  urethra,  and  to  get  the  patient  out 
of  bed  as  much  as  possible. 

The  immediate  convalescence  of  perineal  section  is  likely  to  be  stormy. 
The  patient's  temperature  may  rise  to  103°  F.  immediately  after  opera- 
tion or  immediately  after  removal  of  the  perineal  tube.  The  unfamiliar 
operator  will  have  great  difficulties  with  the  drainage  of  his  tube.  The 


408  STRICTURE  OF   THE   URETHRA 

bladder  will  fill  with  urine  or  with  clots;  the  patient  will  suffer  grave 
agony  and  may  even  die,  septic  and  exhausted,  as  a  result.  But  experi- 
ence and  good  nursing  avoid  these  complications. 

Clots  may  be  sucked  out  of  the  bladder  readily  enough,  and  if  the 
tube  when  placed  properly  does  not  relieve  the  patient's  spasms,  it 
should  be  removed. 

Wliile  the  tube  is  in  place  the  bladder  should  be  irrigated  once  or 
twice  daily,  preferably  with  silver  nitrate  solution. 

After  removal  of  the  tube  no  further  irrigation  is  attempted  so  long 
as  the  patient  progresses  satisfactorily.  An  immediate  rise  of  tempera- 
ture may  be  watched  for  forty-eight  hours.  If  at  the  end  of  this 
time  it  remains  up  a  catheter  should  be  tied  in  and  water  forced. 
Under  these  circumstances  rather  high  doses  of  urotropin  are  sometimes 
of  service.  Good  drainage,  fresh  air,  and  forced  water  are  our  chief 
reliance.  If  all  goes  well  no  instrument  is  introduced  into  the  bladder 
until  about  the  twelfth  day,  when  a  20  or  22  F.  steel  sound  is  passed 
into  the  urethra  after  anesthetization  with  novocain.  If  no  incision  has 
been  made  upon  the  roof  of  the  urethra  the  instrument  is  likely  to  enter 
the  bladder  quite  readily,  but  if  the  roof  has  been  incised  its  point  will 
catch  here  and  need  to  be  deflected  toward  the  floor  before  it  will  pass 
the  stricture. 

If  any  real  difficulty  is  encountered,  this  may  be  overcome  either  by 
introducing  the  finger  into  the  perineal  wound  or  more  neatly  by  passing 
a  grooved  director  from  the  wound  into  the  bladder  and  introducing 
the  sound  on  this;  or  else  by  inserting  the  two  ends  of  a  filiform  into 
the  wound;  one  toward  the  bladder  and  one  toward  the  meatus, 
using  this  as  a  guide.  After  the  introduction  of  the  first  sound  but  one 
more  instrument  should  be  passed,  preferably  a  25  F.  sound.  This  is 
followed  by  an  instillation  of  1  to  1000  silver  nitrate,  the  solution  being 
trickled  along  the  posterior  and  anterior  urethra. 

On  two  occasions  I  have  seen  such  prof  use  bleeding  follow  the  extrac- 
tion of  the  perineal  tube  or  the  passage  of  the  first  sound  that  I  was 
moved  to  give  the  patient  an  anesthetic,  reinsert  a  tube  in  the 
perineum  and  pack  around  it. 

The  subsequent  passage  of  sounds  is  made  at  the  usual  five  or  seven 
days'  interval.  Much  more  skill  is  required  to  enter  the  lacerated 
urethra  than  to  pass  any  stricture.  The  inflammatory  irregularities 
following  operation  persist  for  at  least  a  month.  It  is  wiser  during  the 
first  two  weeks  not  to  attempt  to  stretch  the  urethra  above  25  F.  Sub- 
sequent to  this  the  dilator  should  be  used  and  the  urethra  opened  to 
30  F.  The  fistula  should  heal  within  two  to  six  weeks.  It  requires  no 
particular  care  beyond  the  destruction  of  exuberant  granulations.  The 
healing  may  be  encouraged  by  swabbing  the  sinus  with  trichloracetic 
acid  or  by  touching  with  silver  nitrate  fused  on  a  probe.  If  these  meas- 
ures fail  the  sinus  must  be  excised  and  the  perineum  sutured  in  layers 
around  a  small  tube. 

The  Surgeon  is  Inexpert  or  the  Stricture  is  too  Tight  to  Admit  a  G rootled 
Staff. — The  operation  is  performed  as  above  described  except  that  the 


GONORRHEAL  STRICTURE  OF  THE  MALE  URETHRA       409 

staff  is  cut  down  upon  widely  instead  of  by  touch  and  the  way  into  the 
bladder  is  made  certain  by  a  guide  inserted  through  the  perineal  wound. 

With  the  patient  in  the  lithotomy  position  a  staff  is  inserted  through 
the  stricture,  or  if  this  will  not  enter,  a  filiform  bougie  is  introduced,  and 
upon  this  a  small  tunnelled  staff  is  passed,  either  through  the  stricture 
or  down  to  it.  The  tissues  are  made  tense  over  the  staff  and  divided 
in  the  median  line,  layer  by  layer;  skin,  superficial  fascia,  fat,  muscle 
and  then  the  bulb  itself. 

The  incision  of  the  bulb  is  signalled  by  a  gush  of  blood  which  is  to  be 
disregarded.  The  floor  of  the  urethra  is  incised  just  in  front  of  the 
stricture,  widely  enough  to  expose  the  filiform  and  follower  plainly  to 
view.  With  artery  clamps  the  divided  edges  of  the  mucosa  are  now 
seized.  (The  unfamiliar  operator  wrill  grasp  the  sheath  of  the  corpus 
spongiosum;  this  will  lead  him  nowhere.  He  must  seize  the  mucosa 
itself  on  each  side.)  The  urethra  is  steadied  between  these  clamps,  the 
follower  withdrawn,  but  the  filiform  left  in  place  (or  if  a  grooved  staff 
has  been  employed  this  is  not  withdrawn) . 

The  floor  of  the  urethra  is  then  longitudinally  divided  back  to  the 
point  of  stricture,  the  urethra  being  drawn  out  into  the  perineum  by  the 
application  of  successive  pairs  of  clamps  along  its  cut  edges.  WThen  the 
orifice  of  the  stricture  has  thus  been  brought  into  view  with  the 
filiform  (or  staff)  disappearing  through  it,  a  grooved  director  is  inserted 
in  the  general  direction  of  the  long  axis  of  the  patient's  body  (almost  at 
right  angles  to  the  part  of  the  urethra  that  has  already  been  incised) . 
If  this  grooved  director  is  known  to  be  in  the  bladder,  the  filiform  (or 
staff)  is  withdrawn  and  the  floor  of  the  stricture  divided  by  a  knife 
introduced  into  the  groove  of  the  director.  The  finger  is  then  intro- 
duced into  this  cut  and  guided  by  the  director  until  it  passes  through 
the  dilated  prostatic  urethra  and  the  ring  of  bladder  neck  into  the 
bladder  cavity. 

If  during  any  part  of  the  operation  the  operator  becomes  lost  in  the 
perineum  he  may  usually  find  his  way  by  passing  a  female  catheter 
alongside  of  the  grooved  director;  a  gush  of  urine  through  the  catheter 
announces  that  it  has  reached  the  bladder.  The  rest  of  the  operation 
is  performed  as  described  above,  with  the  exception  that  the  urethra 
may  well  have  been  extensively  damaged  and  require  suturing,  espe- 
cially that  part  of  the  floor  anterior  to  the  point  through  which  the 
perineal  tube  goes.  The  bulbocavernosus  muscle  and  superficial 
tissue  are  also  brought  together  by  catgut  suture  so  as  to  bury  the 
urethra  deep  within  the  perineum  and  thus  to  minimize  the  prospect  of 
persistent  fistula. 

EXTERNAL  URETHROTOMY  WITHOUT  A  GUIDE. — If  after  the  patient 
has  been  anesthetized  no  sound  or  bougie,  large  or  small,  or  even 
filiform,  can  be  introduced  into  the  stricture,  about  20  c.c.  of  0.5  per 
cent,  solution  of  methylene  blue  is  injected  into  the  urethra  and 
patiently  milked  through  the  stricture  and  into  the  bladder  (I  have 
employed  this  device  a  number  of  times  and  have  never  known  the 
coloring  matter  not  to  enter  the  bladder  unless  there  wras  an  open  fistula 


410  STRICTURE  OF  THE   URETHRA 

or  a  large  peri-urethral  abscess).  The  excess  of  solution  is  then  per- 
mitted to  escape  and  the  anterior  urethra  washed  out  with  one  or  two 
injections  of  water,  so  that  no  excess  of  coloring  matter  shall  remain  to 
soil  the  wound  when  the  urethra  is  cut  open. 

The  patient  is  then  put  in  the  lithotomy  position  and  as  large  a  staff 
as  the  urethra  will  admit  is  passed  to  the  face  of  the  stricture  in  the 
perineum.  The  urethra  is  incised  upon  this  as  described  in  the  pre- 
ceding section,  layer  by  layer.  The  mucosa  is  readily  identified  and 
grasped  on  each  side  by  artery  clamps.  The  staff  is  withdrawn.  Now 
comes  the  delicate  part  of  the  operation. 

The  wound  in  the  urethra  and  in  the  superficial  tissues  must  be  wide 
enough  to  permit  the  canal  to  be  drawn  almost  flush  with  the  perineal 
skin.  The  clamps  are  now  steadied  and  the  operator  closely  inspects 
the  urethra,  inserts  the  probe  to  its  deepest  point,  and  gently  incises  the 
floor  of  the  urethra  upon  this.  By  the  aid  of  further  pairs  of  clamps  the 
whole  of  the  urethra  and  the  face  of  the  stricture  are  laid  out  flat  before 
the  operator.  He  now  searches  every  corner  of  this  surface  for  the 
orifice  of  the  stricture  with  the  point  of  a  filiform  bougie.  It  will 
usually  be  found  much  nearer  the  posterior  angle  of  the  wound  (and 
what  might  be  termed  the  lower  surface  of  the  corpus  spongiosum) 
than  would  be  supposed. 

If  the  orifice  of  the  stricture  is  not  found  the  bulbocavernosus  muscle 
is  cut  and  stripped  away  from  the  bulb  (if  more  room  is  needed  the 
superficial  tissues  may  be  divided  transversely  or  in  V-shape).  When 
the  bulb  has  been  freely  exposed  by  good  retraction  of  the  superficial 
tissues  it  is  deliberately  cut  transversely,  posterior  to  the  point  where  it 
has  been  divided  longitudinally,  in  the  vain  search  for  the  orifice  of  the 
stricture.  At  some  point  the  blue  mucosa  will  again  be  encountered 
and  from  this  point  the  passage  into  the  posterior  urethra  with  filiform 
and  grooved  director  is  easy. 

I  have  only  once  failed  to  find  the  orifice  of  the  stricture  by  the  longi- 
tudinal incision  of  the  bulb.  In  that  case  the  transverse  incision  readily 
disclosed  it.  The  surgeon  who  should  fail  by  either  device  is  thereby 
proved  so  unfamiliar  with  the  perineum  that  he  had  better  make  no 
further  attempt  to  find  the  urethra  at  the  apex  of  the  prostate,  but 
rather  take  refuge  in  suprapubic  incision  of  the  bladder  and  retrograde 
caiheterization  by  a  Benique  sound  passed  through  the  bladder  and 
thence  into  the  posterior  urethra.  The  floor  of  the  urethra  is  incised 
upon  the  point  of  this  instrument  and  the  remainder  of  the  operation 
concluded  in  the  usual  manner. 

Other  Devices  for  Finding  the  Orifice  of  the  Stricture. — Various  other 
methods  have  been  employed  to  find  the  way  through  the  stricture. 
Thus  we  may  mention  the  Wheelhouse  staff,  which  is  no  longer  used, 
and  Young's  suggestion  that  we  identify  the  apex  of  the  prostate 
through  the  V-shaped  prerectal  incision  upon  the  membranous  urethra 
and  work  backward  from  this  into  the  stricture.  Any  surgeon  skilful 
enough  to  perform  this  operation  could  much  more  readily  enter  the 
stricture  by  the  method  described  above. 


GONORRHEAL  STRICTURE  OF  THE  MALE   URETHRA       411 

Sinclair's  device  for  retrograde  catheterization  consists  of  a  trocar  and 
cannula,  to  be  plunged  through  the  space  of  Retzius  into  the  bladder, 
after  this  has  been  distended  with  fluid  forcibly  injected  through  the 
urethra  (unless  it  is  already  distended  with  urine).  Through  this 
cannula  a  probe  is  introduced  into  the  posterior  urethra  and  up  to  the 
posterior  face  of  the  stricture.  The  urethra  is  incised  upon  this,  the 
stricture  divided,  internal  urethrotomy  done,  if  necessary,  and  a  soft- 
rubber  catheter  left  in  the  suprapubic  wound  to  drain  the  bladder.  No 
perineal  or  urethral  drain  is  used.  The  inexperienced  surgeon  will  find 
it  much  safer  to  perform  suprapubic  section  for  his  retrograde  catheteri- 
zation, for  there  is  a  distinct  possibility  that  the  trocar  may  enter  the 
peritoneum. 

Under  local  anesthesia  the  opening  of  the  urethra  may  be  found 
if  the  patient  can  be  persuaded  to  urinate. 

RESECTION  OF  THE  URETHRA. — The  urethral  mucosa  grows  with  such 
amazing  rapidity  and  covers  such  incredibly  large  gaps  that  even  when 
the  removal  of  dense  scar  tissue  about  the  urethra  leaves  a  wide  gap  no 
attempt  at  skin  grafting  is  necessary.  Indeed,  such  grafts  rarely  take. 
Sections  of  the  saphenous  vein  have  been  employed  to  take  the  place  of 
portions  of  the  urethra,  but  the  epithelium  does  not  live.  The  only 
requirement  for  filling  a  gap  in  the  urethral  wall  is  to  fix  the  two  ends  of 
the  urethra  as  near  together  as  may  be  and  in  such  a  position  that  a 
sound  will  readily  enter  the  posterior  end,  for  if  subsequent  passage  of 
sounds  is  possible,  we  may  look  for  a  happy  outcome. 

Cabot's  Resection. — Hospital  surgeons  impressed  by  the  frequency 
with  which  patients  return  after  a  few  years'  interval  for  repeated 
perineal  sections  have  endeavored  to  devise  operations  whereby  better 
results  could  be  obtained  and  the  stricture  perhaps  definitely  cured. 
The  two  modern  efforts  to  achieve  this  result  are  Marion's  and  Cabot's. 
The  former  is  not  applicable  to  stricture  but  is  an  excellent  operation 
for  the  treatment  of  rupture  of  the  urethra  (q.  v.).  The  aim  of  Cabot's 
operation  is  to  divide  the  stricture  upon  the  floor  of  the  urethra  in  the 
usual  manner  and  to  reunite  the  longitudinal  incision  by  transverse 
suture,  thus  puckering  the  urethra,  as  it  were,  and  enlarging  the  lumen  of 
the  stricture. 

The  steps  of  the  operation  are  as  follows :  The  urethra  is  steadied  by 
a  sound  instead  of  a  staff.  The  bulb  is  exposed  in  the  usual  manner  but 
not  incised.  The  bulbocavernosus  muscle  is  stripped  away  and  the 
bulb  itself  separated  from  the  corpora  cavernosa  for  a  space  of  at  least 
3  cm.  The  bulb  is  now  opened  over  the  point  of  the  sound  and  the 
stricture  incised  in  such  a  manner  that  the  urethra  is  opened  for  a  short 
distance  behind  as  well  as  in  front  of  it.  Beginning  at  the  tightest  point 
of  the  stricture  (i.  e.,  approximately  at  the  middle  of  the  longitudinal 
incision  in  the  bulb)  the  adjacent  edges  of  the  mucosa  and  underlying 
corpus  spongiosum  are  sutured  transversely  with  fine  catgut  introduced 
on  a  curved  intestinal  needle.  A  small  sound  is  left  in  the  urethra  while 
successive  sutures  are  taken  in  each  side  and  clamped,  but  not  tied, 
until  the  whole  wound  has  been  caught  in  sutures  running  from  before 


412  s77(7r'777»'/s   OF   THE    URETHRA 

backward  and  calculated  to  close  the  wound  transversely  on  the  sound 
in  the  urethra.  The  sutures  are  then  tied,  beginning  with  the  ones  first 
introduced  and  ending  with  those  central  ones  that  approximate  the 
anterior  and  posterior  ends  of  the  original  incision.  Drainage  is  pro- 
vided by  a  small  catheter  introduced  into  the  urethra  at  a  point  pos- 
terior to  the  incision  in  the  stricture.  The  perineum  is  sutured  over  the 
incision  in  the  urethra;  the  small  catheter  left  in  place  for  two  weeks; 
the  bladder  irrigated  daily.  Cabot  advises  daily  gentle  injection  of 
argyrol  into  the  anterior  urethra.  ^Ye  have  thought  that  the  trauma 
from  this  did  more  harm  than  the  antisepsis  did  good. 

Cabot's  operation  is  obviously  only  applicable  to  relatively  narrow 
strictures.  In  seven  or  eight  cases  it  has  given  me  better  results  than 
simple  urethrotomy ;  but  the  urethra  is  much  puckered  by  the  opera- 
tion and  one  must  be  extremely  gentle  in  the  first  attempts  to  introduce 
sounds. 

RESECTION  OF  FISTUL.E,  ETC. — External  urethrotomy  for  stricture 
may  be  complicated  by  peri-urethritis,  fistula,  etc.,  or  by  masses  of  scar 
left  by  ancient  peri-urethritis.  The  following  rules  should  guide  the 
operator,  viz.: 

1 .  The  main  incision  should  be  in  the  central  line  of  the  perineum,  no 
matter  how  many  accessory  incisions  are  required. 

2.  Fistulae  must  be  widely  opened  to  their  ultimate  ramifications.     A 
pocket  in  the  perineum  will  not  heal. 

3.  Masses  of  hard  scar  tissue  must  be  excised,  even  though  this  sacri- 
fice the  urethral  wall.     But  every  effort  must  be  made  to  leave  an  even 
roof  to  the  urethra  as  a  guide  to  sounds. 

4.  It  is  preferable,  though  not  essential,  to  excise  the  fibrous  walls  of 
all  fistulse. 

5.  If  the  urethra  has  been  completely  divided  its  roof  must  be 
repaired  as  well  as  possible  and  its  floor  left  wide  open  so  that  sub- 
sequent sounds  may  readily  enter  the  posterior  segment. 

6.  In  order  to  avoid  subsequent  fistula  the  perineum  must  be 
reconstructed  as  well  as  possible. 

TRAUMATIC  STRICTURE. 

The  urethra  may  be  torn,  punctured,  or  incised  in  any  part  of  its 
course.  Punctures  or  linear  incisions  (e.  g.,  false  passages  from 
rough  instrumentation,  tears  resulting  from  the  extraction  of 
calculi  or  foreign  bodies,  bullet  wounds,  urethrotomy  incisions,  etc.) 
usually  heal  without  leaving  any  stricture;  for  unless  peri-urethritis 
ensues  the  scar  occupies  so  small  a  portion  of  the  circumference  of  the 
canal  that  its  contraction  does  not  appreciably  encroach  upon  the 
lumen. 

The  types  of  injury  likely  to  result  in  stricture  are  (1)  the  so-called 
straddle  injury  (whereby  the  membranous  urethra  is  partly  or  wholly 
torn  across);  (2)  fracture  of  the  pelvis  (with  the  same  result);  (3) 
prostatectomy  (which  may  leave  a  stricture  at  the  bladder  neck); 


TRAUMATIC  STRICTURE  413 

(4)  the  Bottini  operation  (which  may  so  cauterize  the  junction  of  the 
bulbous  and  the  membranous  urethra  as  to  leave  stricture  there) ,  and 

(5)  injuries  to  the  erect  penis  (such  as  breaking  a  chordee). 

With  the  postprostatectomy  stricture  we  have  no  concern  here.  Of 
the  others  it  may  be  said  that  they  contract  much  more  rapidly,  require 
operation  for  their  relief  much  more  often,  and  recur  after  operation 
with  much  greater  obstinacy  than  do  gonorrheal  strictures.  Thus, 
among  44  personal  cases,  all  appeared  within  six  months  of  the  injuries 
excepting  4.  Although  an  interval  of  from  five  to  twenty  years  in- 
tervened in  these  4  cases  between  the  trauma  and  the  diagnosis  of 
stricture,  each  one  had  received  more  or  less  treatment  during  this 
interval;  treatment  that  might  have  controlled  the  stricture  in  some 
degree.  But,  as  a  rule,  traumatic  stricture,  from  whatever  cause,  defies 
such  casual  treatment  and  contracts  very  rapidly.  Among  28  accu- 
rately described  cases  I  find  23  impassable  or  filiform  in  size,  the  other 
5  had  contracted  to  10,  15,  17,  18  and  24  F.  Of  44  cases  tabulated,  31 
were  operated  upon  in  our  office  and  many  others  elsewhere.  Ob- 
viously, traumatic  stricture  contracts  much  more  obstinately  than 
gonorrheal  stricture. 

Pathology. — The  pathological  changes  that  constitute  traumatic 
stricture  are  but  the  scars  left  by  the  various  types  of  ruptures  in  the 
urethra  mentioned  above.  As  Bazy  has  pointed  out,  the  rupture  may  be 
so  slight  that  only  the  mucosa  is  torn,  but,  as  a  rule,  the  whole  thickness 
of  the  urethra  has  been  divided  in  part  or  all  of  its  circumference.  The 
typical  resulting  scar  therefore  is  a  narrow  one  as  contrasted  with  the 
broad,  irregular  scar  of  gonorrheal  stricture;  but  it  is  a  dense  and  elastic 
scar,  contracting  rapidly  and  resisting  dilatation. 

Symptoms  and  Course. — The  chronic  urethral  discharge  (gleet)  wrhich 
is  the  prevailing  symptom  of  gonorrheal  stricture  cuts  but  a  slight 
figure  among  the  symptoms  of  traumatic  stricture.  Thus  among  21 
cases  only  2  showed  gleet  as  a  first  symptom,  while  10  complained  of 
frequent  and  obstructed  urination,  and  9  of  acute  retention.  In  many 
instances  the  stricture  came  on  so  immediately  after  the  injury  that  the 
hematuria  which  is  so  prominent  a  symptom  of  rupture  of  the  urethra 
was  also  the  first  symptom  of  the  stricture  itself.  Indeed,  the  symp- 
toms of  stricture  usually  follow  immediately  upon  those  of  the  rupture. 
If  the  injury  is  so  severe  that  the  patient  cannot  urinate  or  requires 
attention  for  other  injuries  the  urethral  rupture  is  immediately  diag- 
nosed, the  patient  is  operated  upon,  and  if  properly  treated  he  may  be 
relieved  from  any  symptoms  of  stricture  for  a  considerable  time.  Thus 
wreeks,  months,  and  exceptionally  years  may  intervene  before  the  trau- 
matic stricture  is  diagnosed.  But  if  the  injury  is  only  severe  enough  to 
cause  slight  hematuria  the  patient  may  not  consult  a  physician,  no 
attempt  may  be  made  to  treat  the  condition,  and  always  within  a  few 
weeks  the  stricture  declares  itself  by  obstructing  urination. 

The  very  beginning  of  traumatic  stricture  therefore  depends  largely 
upon  treatment,  and  its  subsequent  course  is  even  more  dependent  upon 
this.  Operation  which  is  not  often  necessary  in  the  treatment  of 


414  STRICTURE  OF  THE   URETHRA 

gonorrheal  stricture  is  almost  invariably  an  essential  part  of  the 
treatment  of  traumatic  stricture.  The  stricture  must  be  incised.  If 
it  recontracts  thereafter  it  must  be  incised  again.  Thus  only  will  its 
tendency  to  recontraction  be  finally  overcome. 

Treatment. — A  slight  injury  to  the  urethra  sufficiently  severe  to  cause 
hemorrhage  should  at  least  be  identified  by  urethroscopy  and  treated 
by  the  passage  of  sounds  according  to  the  rules  already  laid  down. 
Graver  injuries,  including  almost  all  injuries  to  the  bulb  and  posterior 
urethra,  require  prompt  perineal  section  and  subsequent  sounding  as 
a  preventative  of  stricture.  Doubtless  stricture  will  follow  such 
operation,  but  it  will  be  less  resilient  and  intractable  than  if  the  oper- 
ation had  not  been  done. 

For  the  cure  of  traumatic  stricture  internal  urethrotomy  for  anterior 
strictures  and  external  urethrotomy  for  stricture  of  the  membranous 
urethra  yield  surprisingly  good  results.  If  the  after-treatment  is  con- 
ducted for  a  sufficient  length  of  time,  as  stated  above,  the  failure  of 
one  perineal  section  is  no  reason  why  another  will  not  succeed. 

On  several  occasions  patients  have  come  to  me  in  despair  on  account 
of  the  recurrence  of  symptoms  or  the  physician's  inability  to  pass 
sounds  a  few  weeks  after  operation.  They  \vere  promptly  put  in  the 
hospital,  the  stricture  reincised,  and  thereafter  the  case  presented  no 
unusual  difficulties.  Such  patients  I  have  had  under  control  for  as 
long  as  ten  years.  They  need  rather  more  frequent  dilatation  than 
gonorrheal  patients,  but  they  are  just  as  controllable;  and  once  the 
operative  wound  has  healed  and  the  stricture  takes  a  full-sized  sound 
its  resilience  is  usually  conquered. 

CONGENITAL  STRICTURE. 

Congenital  narrowing  of  the  urethral  lumen  may  be  very  considerable 
and  yet  cause  no  symptoms.  Hence  the  pathological  condition  must 
be  distinguished  from  the  clinical.  The  former  must  be  considered 
first. 

Englisch,1  in  his  compendious  study,  has  collected  155  cases  of  atresia 
and  208  of  congenital  stricture  affecting  every  portion  of  the  urethra; 
for  although  the  urethra  is  indeed  developed  from  three  sources  (the 
posterior  urethra  from  the  urogenital  sinus,  the  balanitic  from  an  infold- 
ing of  skin,  and  the  intervening  anterior  urethra  from  the  penile  groove) 
nevertheless  congenital  stricture  may  occupy  any  portion  of  the  canal. 
It  may  be  membranous  or  fibrous.  A  large  if  not  a  major  proportion 
of  strictures  are  not  associated  with  other  defects  of  development. 
The  stricture  is  usually  of  no  great  width  (in  contrast  with  atresia 
which  may  extend  over  the  greater  part  of  the  urethra) . 

The  meatus  urinarius  and  the  so-called  second  meatus  (a  constriction 
at  a  depth  of  about  1  cm.  within  the  urethra)  are  the  usual  site  of  con- 
genital stricture.  Indeed,  in  this  region  it  is  familiar  to  all  while  else- 
where it  is  extremely  uncommon  (I  have  seen  less  than  half  a  dozen 
clinical  cases). 


OTHER  TYPES  OF  STRICTURE  OF  THE  MALE  URETHRA   415 

Etiology. — The  cause  of  congenital  stricture  is  either  maldevelopment 
or  inflammation  of  the  urethra  before  birth.  (Englisch  believes  that 
some  so-called  congenital  strictures  are  the  result  of  non-gonorrheal 
urethritis  in  infancy,  due  to  balanitis,  masturbation,  or  the  exan- 
themata.) 

Pathology. — The  stricture  may  be  due  to  a  valve  of  mucosa,  to  a 
constriction  of  all  coats  of  the  urethra,  or  to  scar. 

Complicating  hypospadias,  dilatation,  and  fistula  are  not  uncommon. 
Tight  stricture  results  in  dilatation  of  the  upper  urinary  tract  similar 
to  that  which  results  from  retention  in  later  life. 

Clinical  Types. — 1.  The  tightest  strictures,  amounting  almost  to  com- 
plete atresia,  produce  enormous  renal  dilatations  which  either  kill  the 
child  at  about  the  time  of  birth  or  gravely  interfere  with  parturition 
because  of  their  size.  The  interest  of  such  cases  is  purely  pathological 
and  obstetrical.  The  stricture  is  often  found  in  the  region  of  the 
verumontanum.3 

2.  If  the  stricture  permits  the  infant  to  survive,  symptoms  are  often 
first  noted  between  the  fifth  and  tenth  years.     Congenital  stricture  may 
be  suspected  in  cases  of  (a)  incontinence  of  urine,  especially  if  this  be 
diurnal,  (b)  poor  nutrition  associated  with  evidence  of  renal  deficiency, 
(c)  unexplained  hematuria. 

3.  The  stricture  may,  however,  have  so  large  a  caliber  that  it  excites 
no  symptoms  until  in  adult  life  an  intercurrent  urethritis  calls  attention 
to  it.     If  the  urethritis  is  gonorrheal  the  true  origin  of  the  stricture  is, 
of  course,  overlooked.     Bazy  therefore  insists  that  congenital  strictures 
are  much  more  common,  than  we  suppose. 

4.  The  stricture  interferes,  with  the  passage  of  urethral  instruments. 
Most  meatus  strictures  fall  in  this  category. 

Diagnosis. — This  is  usually  made  by  the  exclusion  of  trauma  and 
gonorrhea  (except  in  the  case  of  meatus  strictures). 

It  has  been  my  good  fortune  to  identify  congenital  strictures  thrice 
by  careful  perineal  section. 

It  is  difficult  to  arrive  at  a  clinical  criterion  as  to  the  exact  amount  of 
constriction  that  constitutes  a  congenital  stricture.  Certainly  only 
those  strictures  require  attention  that  cause  retention,  interfere  with  the 
cure  of  urethritis  or  prohibit  the  passage  of  urethral  instruments. 
Doubtless  it  is  fair  to  consider  any  stricture  tighter  than  18  F.  a  poten- 
tial, if  not  an  actual,  cause  of  retention. 

Treatment. — Englisch  wisely  observes  that  "the  earlier  the  obstacle 
develops,  the  more  extended  are  the  alterations  of  the  urinary  tract 
higher  up."  He  believes  that  treatment  by  dilatation  is  often  useful. 
Stricture  of  the  meatus  will  not  dilate.  It  must  be  cut.  All  the  deeper 
strictures  I  have  recognized  have  required  operation. 

OTHER  TYPES  OF  STRICTURE  OF  THE  MALE  URETHRA. 

Tuberculosis. — Tuberculosis  of  the  prostate  very  rarely  results  in 
urethral  constriction.  Occasionally  it  causes  a  stricture  of  the  bladder 


416  STRICTURE  OF   THE   URETHRA 

neck,  producing  frequency  of  urination  or  residual  urine.  This,  if  not 
organized,  yields  to  (and  its  symptoms  disappear  following)  the  passage 
of  the  cystoscope.  Cicatricial  stricture  of  the  deep  urethra  after  the 
subsidence  of  the  prostatic  lesion  requires  operation  for  the  contracture 
(q.  v.*). 

Tuberculosis  of  the  anterior  urethra  is  so  rare  that  it  may  be  dis- 
missed with  the  statement  that  it  is  usually  unimportant  but  may 
require  the  routine  treatment.8 

Syphilis. — The  scar  of  gumma  about  the  meatus  may  cause  stricture. 
The  existence  of  syphilitic  stricture  of  any  importance  elsewhere  in  the 
urethra  is  doubtful.9 

Chancroid. — This  may  also  leave  a  scar  that  constricts  the  meatus. 

Bilharzia. — Pfister7  states  that  stricture  of  the  prostatic  urethra  may 
result  from  Bilharzial  inflammation.  The  infection  may  rarely  extend 
to  the  anterior  urethra  and  even  to  the  corpora  caver nosa. 

Stone,  Foreign  Bodies,  and  Cancer  may  obstruct  the  urethra. 
They  can  scarcely  be  said  to  cause  stricture. 

STRICTURE  OF  THE  FEMALE  URETHRA. 

Stricture  of  the  female  urethra,  whether  congenital,  traumatic,  or 
gonorrheal,  merits  only  that  its  existence  be  known.  Like  stricture  of 
the  male  urethra  it  is  a  cause  of  frequent  urination,  pyuria,  retention. 
It  may  be  relieved  by  dilatation  or  by  internal  urethrotomy. 

BIBLIOGRAPHY. 

1.  Englisch:  Folia  Urolog.,  1909,  iv,  288,  376. 

2.  Halle:  Annal.  d.  ural.  d.  org.  Gen.-Urin.,  1891,  ix,  143;  1894,  xii,  244. 

3.  Heinecke:  Zeit.  f.  Urol.,  1913,  ii,  No.  1. 

4.  Keyos:  Trans.  Amer.   Genito-urinary   Surg.,    1915. 

5.  Keyes  and  MacKenzie:  New  York  Med.  Jour.,  November  9,  1912. 

6.  Minet:  Guyon's  Annales,  1911,1,46. 

7.  Pfister:  Verhandl.  d.  Deut.  Gesellsch.  f.  Urol.,  1911,  iii. 

8.  Sawamura:  Folia  Urol.,  1910,  iv,  No.  9. 

9.  Tauton:  Progress  Med.,  1910,  p.  607. 

10.  Thompson:  Stricture  of  the  Urethra,  1858,  2d  edition,  p.  84. 


SECTION  III. 

DISEASES  OF  THE  SCROTUM  AtfD 
TESTICLE. 


CHAPTER  XII. 

ANATOMY  AND  PHYSIOLOGY,  MALFORMATIONS, 
INJURIES  AND  TORSION  OF  THE  TESTICLE. 

BY  GEORGE  GILBERT  SMITH,  M.D. 

THE  TESTICLE  AND  EPIDIDYMIS. 

Embryology. — The  testicles  develop  during  the  first  third  of  fetal 
life.  Each  testis  appears  first  as  the  genital  ridge  upon  the  ven- 
tromesial  border  of  each  Wolffian  body  (Fig.  173).  Peritoneal  inf old- 
ings  give  rise  to  solid  cords  of  cells  which  extend  inward  from  the  peri- 
toneal surface  of  the  genital  ridges  to  connect  with  the  glomerular 
capsules  of  some  of  the  Wolffian  tubules  (Fig.  174).  Before  reaching 
the  glomeruli,  these  cords,  which  later  acquire  lumina,  form  a  net  of 
anastomosing  tubules,  which  becomes  the  rete  testis.  Of  the  Wolffian 
tubules,  ten  to  fifteen  are  utilized  in  this  way.  The  glomeruli  atrophy 
and  the  tubules  become  coiled  canals  which  form  the  ductuli  efferentes 
in  the  globus  major  of  the  epididymis.  The  Wolffian  duct,  into  which 
they  empty,  persists  as  the  ductus  epididymidis  and  its  continuation, 
the  vas  deferens.  Of  the  Wolffian  tubules  not  utilized  in  this  way,  one 
or  more  may  persist  as  very  small  pedunculated  bodies  springing  from 
the  globus  major  or  from  the  upper  pole  of  the  testicle.  The  organ  of 
Giraldes  or  paradidymis  is  thus  explained ;  the  hydatid  of  Morgagni  is 
said  to  be  a  remnant  of  the  duct  of  Miiller.  (In  the  female  the  duct 
of  Miiller  becomes  the  Fallopian  tube.)  One  or  more  of  the  lower 
Wolffian  tubules  may  persist  as  aberrant  ducts  leading  off  the  ductus 
epididymidis  in  the  globus  minor23  (Fig.  175). 

Descent  of  Testicle. — As  the  testicle  takes  definite  shape  a  fold  of 
peritoneum  develops,  extending  from  the  lower  pole  of  the  testis  down- 
ward and  outward  across  the  iliac  fossa.  In  the  free  border  of  this  fold 
develops  the  gubernaculum,  a  cord  of  connective  tissue,  in  which  are 
found  smooth  muscle  fibers,  supposedly  derived  from  the  muscles  of  the 

M  u    i—27  (  417  ) 


418 


IX JURIES  AND  TORSION  OF  THE  TESTICLE 


FIG.  173. — From  a  reconstruction  of  a 
13.6  mm.  human  embryo  (F.  ~W.  Thyng). 
bl.,  bladder  ;/.,nmbriae;  g.g.,  genital  ridge ; 
g.p.,  genital  papilla;  Af.d.,Mullerian  duct; 
p.,  renal  pelvis;  r.,  rectum;  ur.,  ureter; 
MX.,  urogenital  sinus;  W.d.,  Wolffian  duct. 
(Lewis  and  Stohr.) 


FIG.  174. — Diagram  of  the  development 
of  the  testis,  based  upon  figures  by  Mac- 
Callum  and  B.  M.  Allen,  c.,  glomerular 
capsule;  i.e.,  inner  or  sex  cords;  M.d., 
Miillerian  duct;  o.c.,  outer  or  rete  cords; 
W.d.,  W.t.,  Wolffian  duct  and  tubule. 
(Lewis  and  Stohr.) 


urettf 


urethra 


appendix  epididymidis 
.appendix    teslis 


.convoluted  tubule 


straight  tubiilt 


seminal  vesicle 
I—  prostatic  gland. 


ductus  deferent 

paradidymis 
ductitlus     efferent 


rcie  testis 

ditctulns   aberrant 
ductus  epididymidis 


FIG.  17o. — Diagram  of  the  male  sexual  organs  (Modified  from  Eberth,  after  Waldeyer.) 
The  course  of  the  Mtillerian  duct  is  indicated  by  dashes.      (Lewis  and  Stohr.) 


THE  TESTICLE  AND  EPIDIDYMIS 


419 


abdominal  wall.17  Inferiorly  the  gubernaculum  has  attachments  in 
Searpa's  triangle,  to  Poupart's  ligament,  to  the  pubic  bone,  to  the  root 
of  the  penis,  to  the  perineal  fascia  and  ischium,  and  to  the  bottom  of  the 
scrotum.17  As  the  lumbar  spine  grows,  the  testicle  is  left  behind,  so  to 
speak,  and  thus  begins  its  descent.  Whether  further  descent  comes 
about  through  the  same  means — that  is,  by  the  body  growing  away 


T.v. 


p. 


T.v. 


P,     Peritoneum. 
T.     Testicle. 

S.     Scrotum. 


T.V. 


P.V.  Processus  vaginalis. 

T.V.  Tunica  vaginalis. 

F.C.  Fibrous  cord  or  tliread. 
Inguinal  Canal. 


FIG.  176. — Diagram  of  the  descent  of  the  testicle.     (Watson  and  Cunningham.) 

from  the  testicle — or  whether  the  gubernaculum  shrinks  and  exercises 
an  active  pull  is  not  known.  The  fact  remains  that  by  the  sixth  month 
the  testis  is  at  the  internal  inguinal  ring,  drawn  down  by  the  guber- 
naculum and  connected  with  its  place  of  origin  by  the  spermatic  vessels. 
The  vas  deferens,  the  lower  end  of  which  is  now  attached  to  the  pros- 
tate, is  drawn  outward  and  downward,  passing  in  front  of  the  ureter  and 
hooking  over  it. 


420 


IX. JURIES  AND   TORSI  OX   OF   THE   TESTICLE 


During  their  descent  the  testicle  and  epididymis  have  been  sur- 
rounded by  peritoneum  except  where  the  membrane  is  reflected  off  the 
epididymis.  A  diverticulum  of  the  peritoneal  cavity,  the  processus 
vaginalis,  has  preceded  the  testis  into  the  scrotum.  The  testicle  enters 
the  inguinal  canal,  passes  out  through  the  external  ring,  and  at  birth  or 
shortly  after  reaches  its  position  in  the  scrotum.  The  peritoneal  canal 
then  becomes  obliterated  in  its  upper  part,  leaving  the  lower  part  to 
form  a  serous  sac  for  the  testicle  (Fig.  176). 

ANATOMY  OF  THE  TESTICLE. 

The  testes  are  a  pair  of  somewhat  oval,  slightly  flattened  bodies  of  a 
grayish-white  color,  measuring  about  an  inch  and  a  half  in  length,  one 
inch  from  before  backward,  and  rather  less  in  thickness.7  As  the  tes- 
ticles hang  in  the  scrotum  the  long  axis  is  directed  upward,  slightly 
forward  and  outward  (Figs.  177  and  178). 


spermatic 
'    cord 
cremaster) 


tunica  vaginalis 
propria 

superior  extremity 

appendix 
of  testis 


head  of 
'epididymis 

appendix  of 
''  epididymis 


lateral  surface  ,-• 


^medial  surface 


^anterior  border 


j_  \tunica  vaginalis 
coinmunis 


inferior  extremity 


FIG.   177. — The  testis  and  epididymis,  with  their  investing  membranes,  seen  from  in 

front.     (Sobotta.) 


The  posterior  border  of  the  testis  bears  a  crescentic  body,  the 
epididymis.  The  upper  extremity  of  the  epididymis,  or  globus  major, 
lies  upon  the  upper  pole  of  the  testis  and  is  enveloped  by  a  serous  cover- 
ing except  at  its  attachment  to  the  testicle.  The  body  of  the  epididymis 
is  applied  against,  but  is  separated  from  the  testis  by  an  infolding  of  the 
serous  covering  of  the  organ,  which  forms  an  intervening  pocket  termed 


ANATOMY  OF  THE   TESTICLE 


421 


th<>  digital  fossa.  The  lower  and  smaller  extremity,  or  globus  minor,  is 
attached  to  the  testis  only  by  connective  tissue  and  by  the  serous  cover- 
ing. From  the  globus  minor  the  vas  deferens  proceeds  upward  in  the 
loose  tissue  outside  the  serous  sac. 

The  spermatic  cord,  which  contains  the  bloodvessels  of  the  testis, 
enters  that  organ  at  a  point  on  the  posterior  superior  border,  mesial  to 
the  epididymis. 

Arising  from  the  groove  between  the  globus  major  and  the  testicle  is  a 
fairly  constant  structure,  the  appendix  testis,  or  hydatid  of  Morgagni. 
This  has  been  found  in  90  per  cent,  of  testes  examined  and  is  a  peduncu- 


sper matte  cord  --- 

tunica  vaginalis  propria 
superior  ligament  of  epididymis 

sinus  of  epididymis 

& 
posterior  border  of  testis 

inferior  ligament  of  epididymis 

tail  of  epididymis 


tunica  vaginalis  commnnis 

head  of  epididymis 
appendix  of  testis 
appendix  of  epididymis 


lateral  surface 
of  testis 


anterior  border 
of  testis 


FIG.   178. — The  testis  and  epididymis,  with  their  investing  membranes,  seen  from  the 

lateral  surface.     (Sobotta.) 

lated  tumor  consisting  of  vascular  connective  tissue  and  containing 
fragments  of  canals  lined  with  simple  columnar  epithelium,  sometimes 
ciliated.23  It  is  thought  to  represent  the  Miillerian  duct.  Attached  to 
the  globus  major  of  the  epididymis  is  the  paradidymis,  or  organ  of 
Giraldes. 

The  tunica  vaginalis,  which  lines  the  cavity  in  which  the  testis  and 
epididymis  are  contained,  consists  of  a  parietal  portion  and  a  visceral 
portion.  The  parietal  layer  extends  for  some  distance  above  the  testis, 
and  the  space  wrhich  it  lines  is  considerably  larger  than  the  organs  con- 
tained therein.  The  testis  and  epididymis  are  completely  invested  by 
the  visceral  portion,  save  at  the  points  of  contact  between  the  two,  at 


422 


IXJt'KIES   AXD    TORSfO.V  OF   THE   TESTICLE 


the  posterior  border  of  the  testis,  where  the  spermatic  cord  is  attached, 
and  at  the  inner,  posterior  aspect  of  the  epididymis. 

The  attachment  of  the  testis  to  the  scrotum  at  this  point  is  frequently 
called  the  mesorchium.  As  Rigby  and  Howard40  have  pointed  out,  the 
mesorchium,  properly  speaking,  lies  between  testis  and  epididymis,  and 
is  usually  short ;  the  attachment  of  testicle  and  epididymis  to  the  scrotal 
wall  should  be  called  the  urogenital  mesentery. 

Finer  Structure. — Testis. — The  testis  is  enveloped  in  a  tough  fibrous 
coat  called  the  tunica  albuf/inea.  At  the  point  of  entrance  of  the 
spermatic  vessels  this  becomes  thicker  and  forms  the  mediastinum, 
or  corpus  hif/hmari.  The  inner  layer  of  the  tunica  albuginea  is  very 
vascular,  and  from  it  spring  fibrous  septa  which,  passing  to  the  medi- 
astinum, divide  the  testis  into  some  200  cone-shaped  lobules.  Each  of 


head  of  epididymis 


spermatic  cord 


__       .i.?*.',! 
jffilfoX  'p|; 

*^^"  """  •-.*'  ,'.*    *s.  *r^'.'f         ' .          tncdictstii 

^  »^^       ~»'.\  y '  »   1     .l\     '/I  t^r-4-:, 


tunica  •' 
albuginea  

fail  of  epididymis 
FIG.  179. — Longitudinal  section  of  the  testis  and  epididymis.      (Sobotta.) 

these  contains  three  or  four  seminiferous  tubules,  which  can  be  un- 
ravelled and  appear  to  the  naked  eye  like  fine  threads.  They  unite  to 
form  a  smaller  number  of  straight  tubules,  the  tubidi  recti,  and  these  in 
turn  open  into  the  rete  testis,  a  complicated  network  of  canals  occupying 
the  mediastinum  (Fig.  179). 

Epididymis. — From  the  rete  testis  some  fifteen  or  twenty  ducts,  so 
coiled  as  to  present  cone-shaped  masses  with  their  apices  toward  the 
testicle,  carry  the  secretion  to  the  main  duct  of  the  epididymis.  The 
smaller  ducts  are  the  mm  efferentia,  the  single  duct  is  the  ductus  epid- 
idymidis.  About  20  feet  long  when  unravelled,  this  duct  comprises  the 
body  and  lower  pole  of  the  epididymis,  and  leaves  it  as  the  vas  deferens 
(Fig.  175). 

Histology  of  the  Testicle. — Aside  from  the  connective-tissue  frame- 
work, three  kinds  of  cells  occur  in  the  testis.  Two  of  these  are  found  in 


ANATOMY  OF  THE  TESTK'I.H 


423 


the  seminiferous  tubules— the  ftustentcurular  or  supporting  cells,  often 
called  the  cells  of  Rertoli,  and  the  sexual  cells  (Fig.  180) .    The  latter  may 


Spermatids. 
Sustentacular  cell. 
Spermatogonium. 


Blood  vessel  with 
blood  corpuscles 


Interstitial  cells. 


Fat 
granules 


Spermatids. 


Sustentacular  cell.        Spermatogonia,  beneath         Sustentacular  cells, 
large  spermatocytes. 


FIG.  180. — Cross-sections  of  seminiferous   (convoluted)  tubules  of  a  mouse.      X  360. 

(Lewis  and  Stohr.) 


FIG.  181.  —  Cross-section  of  a 
convoluted  tubule  of  the  testis  at 
birth.  (Eberth.) 


FIG.  182. — Sustentacular  cells,  a,  isolated 
(Kolliker).  b.,  Golgi  preparations.  (Bohm  and 
von  Davidoff.) 


appear  in  any  one  of  the  five  stages  through  which  they  must  pass  before 
becoming  mature  spermatozoa.  (See  Physiology  of  the  Testicle,  p.  427.) 
The  Sustentacular  cells  extend  from  the  basal  membrane  of  the  tubules 


424 


INJURIES  AXD   TORSION  OF   THE   TESTICLE 


toward  the  lumen.  Early  in  life  they  form  a  syncytium;  later,  as 
spermatogenesis  takes  place,  they  become  cylindrical  in  shape,  with  an 
outline  made  irregular  by  the  pressure  of  the  sexual  cells  which  develop 


Heads  of 
spermatozoa. 


Spermatocyte 


Crystalloids  in  _5j{ 

interstitial 
cells. 


Spermatid. 


Nuclei  of  sus- 
tentacular  cells. 


*  !  -  '^ 


Interstitial  con- 
nective tissue. 


I'n;.  is.3. — From  a  longitudinal  section  through  a  convoluted  tubule  of  a  human  testis. 
X  360.     (Lewis  and  Stohr.) 

between  them  (Figs.  181  and  182).  Each  cell  has  an  ovoid  nucleus 
with  a  distinct  nucleolus;  the  protoplasm  contains  fat  droplets,  brown 
granules,  and  at  times  crystalloid  bodies  in  pairs.24 


Tangential  section 

of  a  ductulus 

offerers. 


Connective  tissue. 


Blood  vessel.        Epithelium     Circular  muscles        Transverse  section  of  a 

•  „ '  ductulus  efferens. 


of  the  ductus  epididymidis. 

FIG.  184.  —  From  a  section  of  the  head  of  a  human  epididymis,  showing  sections  of  the 
ductus  epididymidis  in  the  centre  and  of  ductuli  efferentes  on  the  sides.  X  50.  (Lewis 
and  Stohr.) 


The  third  kind  of  cell,  the  interstitial  cell,  or  cell  of  Leydig,  occurs 
in  the  loose  connective  tissue  between  the  tubules.    These  cells  are 


.\.\~ATOMY  OF  THE  TESTICLE  425 

derived  from  the  mesothelium  of  the  genital  ridge ; ll  they  are  usually 
round  or  polygonal  in  shape,  without  distinct  cell  boundaries.  Their 
protoplasm  contains  pigment  and  other  granules,  fat  droplets,  and  rod- 
shaped  crystalloids.  During  fetal  life  (Fig.  183)  the  interstitial  cells 
are  relatively  abundant ;  after  birth  they  rapidly  diminish  and  are  not 
much  in  evidence  until  puberty,  when  they  undergo  a  renewal  of  growth 
and  remain  constant.  After  puberty  they  recede  somewhat  until 
senile  changes  set  in,  when  they  again  increase. 

Histology  of  Epididymis. — The  epithelium  of  the  convoluted  tubules 
of  the  testis  becomes  more  simple  in  the  tubuli  recti  and  rete  testis,  and 
in  the  efferent  ducts  of  the  epididymis  consists  of  groups  of  columnar 
cells  alternating  with  cuboidal  cells.  Often  the  tall  cells,  and  occasion- 
ally the  short  ones,  are  ciliated.  The  efferent  ducts  have  a  circular 
coat  of  smooth  muscle  fibers  containing  elastic  fibers.  The  duchts 


..Epithelium. 


.Tunica  propria. 


Inner  longitu- 
"dinal  muscles. 


•2"l<V';^jn>    **»'•'•'«•                    '"••'!     Circular 
.\'-A«t-  ^m.:.V  muscles. 


'-   Outer  lofigitu- 
./  "dinal  muscles. 


..^  Connective 
~~^      tissue. 


FIG.  1*5. — Cross-section  of  the  human  ductus  deferens.      X  24.      (Lewis  and  Stohr.) 

epididymidis  is  lined  by  a  two-rowed  epithelium  with  rounded  basal 
cells  and  tall  outer  columnar  cells.  The  latter  have  in  the  middle  of 
their  upper  surfaces  long  non-motile  hairs.  A  thick  circular  muscle 
layer  surrounds  the  duct24  (Fig.  184). 

The  vas  deferens  at  the  epididymal  end  is  lined  with  two-rowed, 
ciliated  epithelium,  and  is  surrounded  by  three  layers  of  smooth  muscle, 
the  inner  and  outer  longitudinal,  the  middle  layer  circular  (Fig.  185). 

Blood  Supply  of  Testicle  and  Epididymis. — The  chief  artery  of  the 
testis  is  the  internal  spermatic,  which  is  given  off  the  abdominal  aorta 
just  below  the  renal  arteries,  supplies  a  branch  to  the  ureter  as  it  crosses, 
and  passes  with  the  spermatic  cord  through  the  inguinal  canal  to  the 
testicle.  Before  entering  the  testis  it  gives  a  branch  to  the  globus 
major  of  the  epididymis.  The  main  stem  then  passes  into  the  medias- 
tinum, where  it  breaks  up  into  many  branches.  These  reach  the 


426  IXJURIEX  AXD   TORSIOX  OF    THE    TESTICLE 

parenchyma  through  the  tunica  va-riiln-a  and  through  the  septule-. 
and  form  capillary  plexuses  around  the  convoluted  tubules.  The  body 
and  tail  of  the  epididymis  are  supplied  by  the  deferential  artery,  which 
adheres  closely  to  the  vas  deferens  until  it  reaches  the  epididymis.  This 
artery  is  a  branch  of  the  inferior  vesical.  or  sometimes  of  the  superior 
vesical.28  A  third  artery  enters  the  lower  pole  of  the  testis  or  epididy- 
mis. This  is  the  external  spermatic,  funicular  or  cremasteric  artery, 
which  is  given  off  the  deep  epigastric  and  runs  in  the  fibrous  sheath  of 
the  spermatic  cord. 

Picque  and  Worms^8  have  shown  that  in  dogs  there  is  free  anastomosis 
between  these  three  arteries.  The  exact  nature  of  the  anastom<>si> 
varies,  but  in  every  case  of  the  24  which  they  studied,  the  existence  of 
such  a  communication  was  clearly  shown.  They  found  no  connection 
between  the  arteries  of  the  testicle  and  those  of  the  scrotum. 

The  veins  follow  the  arteries  in  the  testicle  and  epididymis.  Upon 
issuing  from  these  organs,  they  form  a  plexus,  the  pampiniform  plexus. 
The  plexus  is  part  of  the  spermatic  cord,  and  consists  of  eight  to  ten 
veins;  they  traverse  the  inguinal  canal,  and  near  the  internal  ring  ter- 
minate in  two  main  trunks  which  higher  up  unite  to  form  a  terminal 
stem.  The  right  terminal  vein  enters  the  inferior  vena  cava.  the  left 
one  enters  the  left  renal  vein.  The  spermatic  veins  are  provided  with 
valves  both  in  their  course  and  at  their  terminations,  but  occasionally 
the  valve  at  the  orifice  of  the  left  spermatic  vein  is  absent.7 

Lymphatics. — The  lymphatics  which  drain  the  testes  follow  the 
spermatic  cords  and  enter  the  lumbar  nodes.  These  nodes,  it  will  l>e 
remembered,  also  receive  the  drainage  from  the  kidneys.  The  lymph- 
atics of  the  vas  deferens  empty  into  the  external  iliac  nodes.29 

Nerves. — The  nerves  for  the  testis  accompany  the  spermatic  artery, 
and  are  derived  from  the  aortic  and  renal  plexuses.  In  the  epididymis 
the  nerves  form  the  plexus  myospermaticus,  which  is  a  network  in  the 
muscular  coat  of  the  ducts,  provided  with  sympathetic  ganglia. 

PHYSIOLOGY  OF  TESTICLE  AND  EPIDIDYMIS. 

The  testis  appears  TO  have  two  functions.  One  is  concerned  with  the 
production  and  development  of  spermatozoa,  the  other  has  to  do  with 
the  furnishing  to  the  organism  of  an  internal  secretion.  The  first 
function  is  carried  on  by  the  cells  lining  the  convoluted  tubules,  namely, 
the  sustentacular  cells  and  the  sexual  cells;  the  second,  by  the  inter- 
stitial cells.  The  function  of  the  sustentacular  cells  is  to  support  and 
nourish  the  sexual  cells  during  their  development.  Fig.  1S2  shows 
several  spermatozoa  with  their  heads  embedded  in  the  protoplasm  of  a 
sustentacular  cell.  It  has  already  been  mentioned  that  these  cells 
abound  in  fat .  Von  Ebnerw  has  described  a  circulation  of  this  fat  from 
the  base  of  the  sustentacular  cell  toward  the  lumen  of  the  tubule,  dur- 
ing the  course  of  a  spermatic  generation.  As  the  spermatozoa  devel- 
oped, the  fat  diminished.  Hanes  and  Rosenbloom14  have  shown  that 
the  testes  from  cryptorchid  pigs,  in  which  there  is  very  little  spenna- 


SPERMATIC 
ARTERY 


ANTERIOR 

GROUP  OF 

VEINS 


.CREMASTERIC 
ARTERY 


DEFERENTIAL 
"ARTERY 

SEMINAL 

"DUCT 


POSTERIOR 
-GROUP  OF 
VEINS 


ANASTOMOSIS 

~  OF  VEINS 


The  Arteries  of  the  Testis  and  the  Corel. 


PLATE  IV 


A  B 


FT*--  CA 


Arterial  Supply  of  Human  Adult  Testis.  A  Portion  of  the 
Gland  has  been  Removed  so  as  to  Show  the  Penetration  of  the 
Arteries  through  the  Mediastinum  into  the  Glandular  Tissue. 

A,  B,  main  terminal  branches  to  testicle;  C,  branch  following  spermatic 
cord  and  encircling  and  supplying  vas  deferens;  CA,  eapsular  artery — a 
branch  from  B;  C.E.,  eaput  epididymis — shown  in  outline;  D,  branch  of  eap- 
sular artery  lying  on  innermost  side  of  albuginea;  E,  outline  of  epididymis; 
F,  central  artery  connecting  vessels  of  mediastinum  with  eapsular  branches; 
M,  mediastinum.  X  3£.  (Hill.) 


PLATE   V 


Sagittal  Section  of  Human  Testis;  to  Show  Blood  Supply.  Injected 
with  Red  and  Blue  Celloidin,  cleared  in  1  per  cent.  KOH  and  2O  per 
cent.  Glycerin.  X  4. 

AA,  ascending  artery;  AV,  ascending  vein;  DA,  descending  artery;  DV,  descending 
vein;  M,  mediastinum;  VD,  vas  deferens;  TA,  tunica  albuginea;  TP,  tunica  parietalis. 
(Hill.) 


PHYSIOLOGY  OF  TESTICLE  AND  EPIDIDYMIS 


427 


togenesis,  contain  an  excessive  amount  of  fat,  and  they  have  also  shown 
that  as  the  fat  passes  toward  the  lumen  of  the  tubule,  it  changes  from  a 
neutral  fat  to  a  lipoid. 

No  further  function  of  the  sustentacular  cells  has  been  demonstrated. 

The  sexual  cells  undergo  a  transformation  which  is  called  "  sperma- 
togenesis."  The  cells  pass  through  five  phases :  (1)  The  sperm atogonia, 
or  mother  cells,  lie  nearest  the  basal  membrane  of  the  tubule.  (2) 
Above  them  are  the  primary  spermatocytes,  which  are  larger;  their 
nuclei  usually  show  spiremes  or  other  indications  of  cell  division.  (3) 
Secondary  spermatocytes  lie  still  nearer  the  lumen,  and  beyond  them 
are  (4)  the  spermatids.  Each 
mother  cell  eventually  divides 
into  4  spermatids.  (5)  Each 
spermatid  develops  into  a  sper- 
matozoon. Van  Beneden16  has 
shown  that  in  ascaris  the  number 
of  chromosomes  of  the  mother  cell 
has  been  reduced,  during  these 
cell  divisions,  so  that  each  sper- 
matozoon contains  only  one-half 
as  many  chromosomes  as  did  the 
mother  cell.  Von  Bardeleben4S 
extended  this  discovery  toman, 
and  it  has  been  further  shown 
that  the  mature  spermatozoon 
contains  one-half  the  number  of 
chromosomes  characteristic  of  the 
tissue  cells  of  the  species  in  ques- 
tion16 (Fig.  183). 

The  change  from  spermatid  to 
spermatozoon  is  shown  in  Fig. 
186. 

Mature  spermatozoa  are  di- 
vided into  three  parts — -head, 
neck  and  tail.  When  they  be- 
come free  they  float  in  the  albu- 
minous fluid  secreted  in  small 

amount  by  the  tubules  of  the  testis.  They  pass  to  the  epididymis, 
in  which  they  accumulate  and  in  the  secretion  of  which  they  first 
become  motile.  About  60,000  spermatozoa  occur  in  a  cubic  milli- 
meter of  seminal  fluid.24 

In  addition  to  its  secretory  function  the  epididymis,  according  to 
some  observers,  functions  also  as  an  organ  of  excretion.  Belfield  has 
demonstrated  that  particles  of  dyestuff  after  being  injected  into  the 
anterior  abdominal  wall  may  be  found  in  the  tubules  of  the  epididymis. 
He  attributes  this  to  the  excretory  function  of  the  epididymis,  due 
to  its  derivation  from  the  Wolffian  tubules,  which  were  excretory 
organs. 


FIG.  186.— Diagrams  of  the  development 
of  spermatozoa.  (After  Meves.)  a.c., 
anterior  centrosome;  a./.,  axial  filament; 
c.p.,  connecting  piece;  ch.p.,  chief  piece; 
g.c.,  galea  capitis;  n.,  nucleus;  n.k.,  neck; 
p.,  protoplasm;  p.c.,  posterior  centrosome. 
(Lewis  and  Ftohr.) 


428 


INJURIES  AM)    TORKJOX   OF   THE    TEKTH'LK 


Interstitial  Cells. — It  is  a  well-known  fact  that  if  the  testes  are 
removed  from  man  or  animal  early  in  life  the  castrated  individual  will 
show  failure  of  development  of  the  so-called  "  secondary  sexual  char- 
acteristics."* If  the  testes  do  not  descend  into  the  scrotum  their  sper- 
matogenetic  function  in  many  cases  atrophies.  The  tubules  of  the 
testis  show  fatty  or  fibrous  degeneration,  but  the  number  of  interstitial 
cells  increases.  In  such  cases  the  secondary  sexual  characteristics  are 
well  developed,  and  sexual  desire  may  be  above  the  average.13 

This  seems  fairly  conclusive  evidence  that  the  interstitial  cells  are 
responsible  for  an  internal  secretion  which  has  considerable  influence,  to 
say  the  least,  in  the  development  of  sex  characteristics. 

As  Pappenheim  and  Schwartz35  point  out,  lesions  of  other  glands  of 
internal  secretion,  such  as  the  adrenals  and  pituitary  body,  are  regularly 
accompanied  by  poor  development  of  the  sex  characteristics,  so  that 
the  testes  alone  are  not  responsible.  Pappenheim  and  Schwartz  main- 
tain, furthermore,  that  the  sustentacular  cells  cannot  be  excluded, 
inasmuch  as  they  do  not  atrophy  in  many  cryptorchids.  Whitehead51 
presents  a  case  which  comes  near  to  answering  their  argument.  A  stal- 
lion was  not  cured  of  his  sexual  desire  by  the  removal  of  two  apparently 
normal  testicles.  Two  years  later  a  third  testis  was  removed  from  the 
abdominal  cavity.  His  desire  ceased.  The  testis  on  section  showed 
marked  increase  of  the  interstitial  cells,  and  atrophy  of  the  sustentacular 
cells  as  well  as  of  the  sexual  cells. 

The  interstitial  cells  contain  granules  which  have  the  same  staining 
reactions  as  do  the  granules  in  the  cells  of  other  organs  of  internal 
secretion.  On  the  evidence  so  far  presented  it  seems  justifiable  to  state 
that  the  interstitial  cells  are  at  least  intimately  concerned  in  and  neces- 
sary for  the  normal  development  of  the  secondary  sexual  characteristics. 
There  is  considerable  evidence  to  show  that  their  existence  is  essential 
to  sexual  desire. 


MALFORMATIONS  OF  THE  TESTICLE. 

In  excess 


B.  Anomalies  in 

development 


A.  Anomalies   in 
development 


Anomalies  in 
number 


Anomalies  in 
size 


Polyorchism 

f  Absence    f  Anorchism 
n  deficiency    <  T-.     .  \  0  u- 

\  Fusion       I  Synorchism 


In  excess  Hypertrophy 

In  deficiency       Atrophy 


i  At  some  point  in  its  nor-     Retention 

lestl'le  ,          mal  course 

undescended 


Outside  its  normal  course  Ectopia 

Upside  down  Inversion 

Hind  side  foremost  Retroversion 
(Adapted  from  Monod  and  Terrillon,  p.  2.) 


Testicle 
descended 


*  Such  as  deep  voice,  masculine  form,  hairy  growth  on  body,  etc.,  as  well  as  sexual 
desire. 


MALFORMATIONS  OF  THE  TESTICLE 


429 


Polyorchism. — There  seems  good  evidence  that  cases  of  more  than  2 
testes  have  occurred  in  man.  D.  S.  Lamb19  reviewed  the  literature  on 
this  point,  and  although  he  found  the  condition  mentioned  by  Aristotle 
B.C.  350,  and  a  good  many  times  thereafter  by  other  observers,  he  found 
only  23  cases  in  which  the  theory  was  supported  by  the  presence  of  vas 
or  epididymis  in  connection  with  the  alleged  extra  testicle.  It  cer- 
tainly is  probable  that  in  many  cases  the  observer  was  misled  by  an 
encysted  hydrocele  or  vestigial  tumor,  which  happened  to  yield  testic- 
ular  sensation  when  squeezed.  Lamb  found  reports  of  6  cases,  how- 
ever, in  which  a  third  testicle  was  discovered  at  operation  or  at  autopsy : 
2  of  them  were  in  horses,  1  in  a  dog,  3  in  men. 


i 


FIG.  187. — Ectopic  testis,  transverse  section. 


Lamb  himself  reported  the  case  of  a  man  examined  during  life  by 
Lamb  and  numerous  other  observers,  all  of  whom  agreed  upon  the 
existence  of  a  third  testicle. 

Arbuthnot  Lane20  removed  a  third  testis  from  the  right  side  of  the 
scrotum  of  a  boy,  aged  fifteen  years.  It  was  the  size  of  a  marble,  but 
had  no  testicular  sensation.  It  had  a  tunica  vaginalis  and  vas  deferens 
of  its  own.  Microscopic  sections  were  made.  The  other  testis  occupy- 
ing the  right  side  of  the  scrotum  was  extruded  and  seemed  normal. 
The  left  was  not  exposed,  but  felt  normal  on  palpation. 

Whitehead51  reports  the  examination  of  a  third  testis  removed  from 


430  IXjriilEX   A.\D    TOItMOX   OF    THE    TESTICLE 


the  abdomen  of  a  horse  which  had  had  two  testes  removed  in  the  usual 
manner  two  years  before.  It  seems,  therefore,  that  although  extremely 
rare,  triorchism  may  occur. 

Anorchism.  —  Jacobson17  credits  to  the  French  writers  this  classifi- 
cation of  deficiencies  in  the  seminal  apparatus. 

1.  Absence  of  the  testicle  only. 

2.  Absence  of  the  testicle,  the  epididymis,  and  a  portion,  more  or  less 
extensive,  of  the  vas  deferens. 

3.  Absence  of  the  whole  apparatus. 

4.  Absence  of  all  or  part  of  the  excretory  apparatus,  the  testicle 
being  present. 

5.  Bilateral  anorchism. 

Jacobson,  writing  in  1893,  had  found  recorded  5  cases  of  absence  of 
the  testicle  only.  The  unilateral  absence  of  testis,  epididymis,  and  a 
portion  of  the  vas  was  met  most  frequently;  there  were  but  2  cases 
recorded  of  entire  absence  of  the  whole  seminal  apparatus.  Absence  of 
the  epididymis  alone  may  occur.  Gruber,  professor  of  anatomy  in 
Petrograd,  writing  in  1868,  could  collect  only  23  cases  of  unilateral  and 
7  of  bilateral  anorchism  which  were  verified  by  autopsy.17 

Synorchism.  —  The  fusion  of  both  testicles  within  the  abdomen  has 
been  reported  by  Cruveilhier.6  Their  fusion  within  the  scrotum  has 
been  reported  by  Lenhossek21  and  by  A.  E.  Halstead,12  in  whose  case 
the  epididymes  were  fused  (Fig.  187). 

Hypertrophy  and  Atrophy.  —  The  condition  of  atrophy  of  one  testicle 
is  not  infrequent,  and  many  times  no  history  of  a  preceding  lesion  can  be 
found  to  account  for  the  condition.  In  some  of  these  cases,  the  other 
testicle  appears  to  have  undergone  hypertrophy. 

IMPERFECT  DESCENT  OF  THE  TESTICLE. 

The  descent  of  the  testicle  may  be  stopped  at  any  point.  Retention 
within  the  abdomen  is  the  least  common  variety,  and,  as  the  testis  is 
hidden  from  view,  the  condition  is  called  "  cryptorchism."  The  term  is 
loosely  applied  to  other  forms  of  arrested  descent  as  well.  Within  the 
abdomen,  the  organ  may  remain  in  the  iliac  fossa  close  to  the  spine,  or 
may  stop  just  inside  the  internal  inguinal  ring.  The  most  usual  form  of 
incomplete  descent  is  the  "inguinal,"  in  which  the  testis  is  retained 
within  the  canal.  Or  the  descent  may  stop  just  after  the  testis  has 
emerged  from  the  canal.  (Cruroscrotal  or  scrotofemoral  retention.) 
The  testicle  may  be  movable  and  change  its  positions  frequently,  so 
that  at  times  it  belongs  in  one  group,  at  times  in  another. 

The  cause  of  arrest  of  descent  of  the  testicle  is  not  clearly  worked  out. 
Certain  it  is  that  in  operations  for  this  deformity,  shortness  of  the 
spermatic  vessels  offers  the  greatest  obstacle  to  placing  the  testis  in 
the  bottom  of  the  scrotum.  Eccles10  mentions  a  number  of  conditions 
which  may  be  factors  in  producing  the  anomaly.  These  are  : 

Conditions  associated  with  the  mesorchium  : 

1.  The  mesorchium  may  be  too  long.     The  testis  would  then  hang 


IMPERFECT  DESCENT  OF   THE   TESTICLE  431 

too  freely  within  the  abdominal  cavity,  and  thus  be  prevented  from 
engaging  in  the  opening  into  the  inguinal  canal. 

2.  Adhesions  may  have  formed  between  the  peritoneum  of  the 
mesorchium  and  the  adjacent  portion  of  the  peritoneum. 

3.  An  abnormal  persistence  of  the  plica  vascularis  may  unduly  tether 
the  testis. 

Conditions  associated  with  the  testis  and  its  component  parts: 

1 .  The  spermatic  vessels  may  be  too  short. 

2.  The  vas  deferens  may  be  of  insufficient  length. 

3.  The  testis  itself  may  be  of  abnormal  size  as  compared  with  the 
usual  size  of  the  track  along  which  it  has  to  leave  the  abdomen. 

4.  The  epididymis  may  be  of  abnormal  size. 

5.  There  may  be  a  fusion  of  the  two  testes. 

6.  Certain  forms  of  hermaphroditism. 
Conditions  associated  writh  the  gubernaculum  testis : 

1.  There  may  be  a  deficiency  or  absence  of  the  lower  or  scrotal 
"attachments. 

2.  There  may  be  a  deficiency  of  the  activity  of  its  muscular  fibers. 

3.  Possibly  even  a  want  of  its  upper  attachments  may  lead  to  a  fault 
in  descent. 

Conditions  associated  with  the  cremaster : 

1 .  A  want  of  action  of  the  internal  fibers  of  the  cremaster  before  the 
testis  has  reached  the  inguinal  canal. 

2.  A  retraction  by  the  action  of  the  cremaster  of  the  testis  after  it  has 
gained  its  normal  position  in  the  scrotum. 

Conditions  associated  with  the  route  along  which  the  testis  passes : 

1.  An  ill-development  of  the  inguinal  canal. 

2.  An  ill-development  of  the  superficial  abdominal  ring. 

3.  An  ill-development  of  one-half  of  the  scrotum. 
Other  conditions  not  falling  under  the  above  headings : 

1.  Pressure  of  a  truss  for  an  accompanying  hernia  preventing  the 
onward  passage  of  the  testis  from  the  inguinal  canal  to  the 
scrotum. 

In  certain  cases,  although  the  body  of  the  testis  proper  may  be  re- 
tained within  the  canal,  the  vas  and  even  the  epididymis  may  descend 
to  a  much  lower  level,  and  can  be  felt  outside  the  canal.10 

Incidence. — Incomplete  descent  of  the  testicle  during  the  first  few 
months  of  life  is  quite  common.  Soch  in  the  examination  of  143  male 
infants  of  from  one  to  four  months  of  age,  found  this  condition  in  14 
per  cent.  In  60  per  cent,  of  these  it  was  bilateral.  The  great  majority 
of  such  testicles  descend  during  the  first  year,  and  a  few  of  the  remaining 
descend  during  the  years  before  puberty.  Odiorne  and  Simmons3'  re- 
ported 3  cases  in  wrhich  descent  occurred  at  fourteen  years  of  age. 

In  adults  incomplete  descent  of  the  testicle  is  by  no  means  rare. 
Marshall25  found  12  cases  in  10,800  recruits  (0.1  per  cent.).  Hempel15 
gathered  statistics  which  showed  that  in  7,000,000  Austrian  recruits, 
14,000  were  so  affected  (0.2  per  cent.). 

Neither  side  appears  to  be   particularly  liable  to   this   anomaly 


x  AND  roitsiox  OF  TIIK  TK^ 


432 


(Jacobson).     Of  the  77  cases  reported  by  Odiorne  and  Simmons,  15 
were  bilateral,  39  were  on  the  right  side,  23  on  the  left. 

Ectopic  Testis.  —  When  the  testicle,  instead  of  reposing  at  some  point 
along  the  usual  path  of  its  descent,  lies  outside  that  path,  the  condition 
is  known  as  ectopia.  The  testicle  may  become  ectopic  through  violence 
(see  Injuries  of  Testicle)  ;  the  condition  is  then  known  as  luxation  of  the 
testicle.  Congenital  ectopia  is  believed  to  be  due  to  an  abnormal  pull 
exerted  by  certain  fibers  of  the  gubernaculum,  associated  perhaps  with 
some  abnormality  of  the  testis  or  inguinal  canal  which  hinders  proper 
descent.  Constant  pressure  by  an  accompanying  hernia,  especially  if 
further  progress  is  impeded  by  some  abnormality  ahead  of  the  testicle, 
may  also  be  a  factor  in  driving  it  out  of  its  course  (Eccles). 


FIG.  188.  —  Inguinal  retention,  on  both  sides,  in  a  boy  aged  twelve  years;  interstitial 
Bubvariety.  The  dotted  lines  indicate  the  position  of  the  testes.  The  left  is  a  little 
lower  than  the  right.  The  scrotum  is  ill-developed.  (Osborn.) 


The  varieties  of  ectopia  are  : 

1  .  Interstitial.     The  testicle  lies  properitoneally  (Hempel)  or  in  front 
of  the  aponeurosis  of  the  external  oblique. 

2.  Penile.     The  testis  lies  in  the  soft  tissues  between  the  root  of  the 
penis  and  the  pubes.     Two  cases  have  been  reported  by  W.  Popow,33 
and  one  by  J.  Poupart.37 

3.  Crural  (or  Femoral).     The  testis  lies  in  Scarpa's  triangle.     Jacob- 
son17  quotes  several  cases  in  which  the  testis  left  the  abdomen  by  the 
crural  canal.     Eccles10  casts  doubt  upon  the  accuracy  of  the  observa- 
tions in  such  cases,  and  says  that  in  careful  dissections  the  cord  has 
always  been  found  to  lie  in  front  of  Poupart's  ligament. 

4.  Perineal.     The  testis  lies  in  the  perineum;  the  scrotum  on  the  side 
of  the  ectopia  is  usually  atrophied.     A.  firm  band  of  tissue  holding  the 
testicle  to  the  spine  of  the  ischium  can  generally  be  felt.     This  is  the 


IMPERFECT  DESCENT  OF   THE   TESTICLE  433 

type  of  ectopia  most  frequently  encountered,  and  seems  to  result  in 
less  damage  to  the  testicles  than  do  the  other  kinds15  (Fig.  188). 

5.  Transverse.  Both  testes  descend  by  the  same  inguinal  canal. 
Cases  have  been  reported  by  Lenhossek,21  in  1845,  Jordan,18  in  1885, 
Berg,2  in  1904,  and  A.  E.  Halstead,12  in  1907. 

Inversion  and  retroversion  of  the  testis  need  only  be  mentioned. 
The  latter  condition,  in  which  the  epididymis  is  toward  the  front,  is 
said  by  Rigby  and  Ho\vard39  to  occur  once  in  every  twenty  men,  a 
statement  which  we  cannot  believe  represents  the  facts. 

The  Effects  of  Incomplete  Descent  upon  the  Testis  Itself. — The  effects  of 
incomplete  descent  upon  the  testis  are  much  the  same  whether  the  organ 
is  arrested  in  its  normal  path  or  whether  it  is  ectopic.  The  exposure  of 
the  testicle  to  the  pressure  of  overlying  tissues  and  to  repeated  knocks 


FIG.  189. — Section  from  undescended  testicle  removed  from  man  of  twenty-nine  years. 
Position  pubic.  The  testicle  was  soft,  2x1  cm.  in  diameter,  and  fastened  to  the  wall  of  the 
hernial  sac.  The  greater  part  of  the  organ  was  composed  of  rather  dense  fibrous  tissue 
with  many  small  oval  nuclei  and  containing  large  numbers  of  Reinke's  crystals.  There 
were  many  interstitial  cells.  The  tubules  were  .scattered  irregularly  throughout  the 
sections  and  for  the  most  part  were  represented  by  masses  of  hyaline  tissue.  This  case 
illustrates  the  more  advanced  type  of  atrophy.  (Odiorne  and  Simmons.) 

such  as  a  normally  descended  gland  would  escape  are  the  only  factors 
which  are  known  to  have  a  harmful  influence.1  The  atrophy  is 
probably  due  to  anemia  caused  by  constant  pressure  upon  the  circu- 
lation in  the  testis  and  results  in  small,  soft  testicles  with  disturbed 
function. 

The  fact  remains  that  practically  all  undescended  testicles  show 
definite  changes  in  function  and  in  morphology.  The  spermatogenetic 
function  weakens  or  disappears  entirely;  undescended  testicles  are 
usually,  though  not  always,  sterile.  The  sexual  cells  disappear,  although 
their  supporting  cells,  the  sustentacular  cells,  show  no  alteration  except 
an  increase  in  the  amount  of  fat  which  they  contain.  Men  with  bilateral 
undescended  testes,  on  the  other  hand,  are  not  impotent ;  the  interstitial 
cells  show  hyperplasia,  and  this  overdevelopment  is  more  marked  in 

M  u     I — 28 


434 


INJURIES  AND  TORSION  OF  THE  TESTICLE 


undescended  testes  the  fellows  of  which  are  wanting.  In  some  testicles 
the  degenerative  changes  advance  so  far  that  even  the  interstitial 
tissue  is  affected,  the  entire  testis  becoming  merely  a  fibroma34  (Figs. 
189  to  191). 


FIG.  190. — Section  from  an  inguinal  testicle  from  a  man  of  twenty-three  years.  The 
testicle  was  3  x  1.5  cm.  in  diameter.  There  was  no  increase  in  the  fibrous  tissue,  which, 
however,  contained  many  small  areas  of  interstitial  cells.  The  basement  membrane 
of  the  tubules  was  only  slightly  thickened,  but  they  contained  only  sustentacular  cells, 
no  spermatogenetic  cells  being  seen  in  any  section.  (Odiorne  and  Simmons.) 


FIG.  191. — Section  from  an  inguinal  testicle  from  a  man  of  thirty  years.  The  fibrous 
tissue  was  increased  and  contained  many  interstitial  cells.  The  tubule  in  the  lower 
part  of  the  field  is  nearly  obliterated  by  the  thickening  of  the  basement  membrane. 
The  tubule  in  the  upper  part  of  the  field  showa  active  spermatogenesis  in  the  lower  por- 
tion. (Odiorne  and  Simmons.) 

The  age  at  which  these  changes  occur  is  variable;  authorities  differ 
on  this  point.  The  subject  is  of  considerable  importance,  inasmuch  as 
the  best  time  to  operate  depends  upon  the  age  at  which  degenerative 
changes  commence.  G.  Bellingham  Smith43  examined  six  undescended 


IMPERFECT  DESCENT  OF   THE   TESTICLE  435 

testes  from  boys  under  the  age  of  puberty  and  found  all  of  them  smaller 
than  normal,  with  fewer  tubules  and  more  interstitial  cells.  This 
condition  held  even  in  a  testis  from  a  three-year-old  boy.  On  the 
other  hand,  a  number  of  instances  have  been  reported  of  young  men 
with  both  testicles  undescended  who  have  been  fertile.1  Odiorne  and 
Simmons  published  microphotographs  from  an  undescended  testicle 
in  a  man,  aged  thirty  years,  in  some  of  the  tubules  of  which  active 
spermatogenesis  was  going  on  (Fig.  191).  Beigel1  found  living 
spermatozoa  in  the  semen  of  a  man,  aged  twenty-two  years,  with 
bilateral  inguinal  retention.  Monod  and  Terrillon27  and  Jacobson17 
believe  that  in  young  adults  undescended  testes  may  still  be  fertile, 
but  that  with  the  atrophy  which  is  certain  to  follow,  sterility  is  sure 
to  result. 

In  addition  to  the  above-mentioned  changes  the  undescended  testicle 
is  likely  to  be  tender,  and  is  particularly  liable  to  injury.  If  retained  in 
the  inguinal  canal  the  pressure  of  the  fascia  as  the  abdominal  muscles 
contract  may  be  the  cause  of  pain.  Ectopic  testicles  of  the  perineal 
type  are  particularly  exposed  in  riding  horseback.  Those  of  the  penile 
type  suffer  during  intercourse.  Undescended  testicles  are  liable  to  any 
of  the  diseases  which  affect  the  normal  organ,  perhaps  to  an  even  greater 
degree,  and  the  process,  if  inflammatory,  may  set  up  a  peritonitis 
through  the  open  processus  vaginalis.  Hydrocele  may  exist.  Eccles 
relates  a  case  in  which  the  fluid  collected  in  the  scrotal  part  of  the 
tunica  vaginalis,  while  the  testis  remained  in  the  inguinal  canal. 

Torsion  is  especially  prevalent  in  undescended  testes.  In  the  32 
cases  of  torsion  collected  by  Scudder42  in  1901,  47  per  cent,  were  in 
undescended  testes.  Eccles  (p.  64)  gives  the  following  predisposing 
causes  for  torsion  of  the  retained  testicle : 

1 .  Imperfect  descent  of  the  testis. 

2.  Abnormally  long  mesorchium. 

3.  Practical  absence  of  a  mesorchium. 

4.  Action  of  the  gubernaculum  testis. 

5.  A  congenital  twist  of  the  cord. 

6.  A  roomy  tunica  vaginalis. 

7.  A  flattened  condition  of  an  imperfectly  descended  testis. 

He  believes  that  the  chief  predisposing  cause  at  work  is  partial 
descent  with  a  freely  movable  testis. 

The  exciting  causes  of  torsion  he  considers1  to  be : 

1.  Muscular  effort. 

2.  A  mechanical  twist. 

3.  The  action  of  the  cremaster. 

4.  The  application  of  a  truss. 

5.  Attempts  at  a  reduction  of  the  hernia  by  taxis. 

6.  Approach  of  puberty. 

The  symptomatology,  pathology  and  treatment  of  torsion  will  be 
taken  up  under  Torsion  of  the  Testicle. 

Coincident  with  failure  in  the  descent  of  the  testicle,  there  fre- 
quently exists  failure  of  the  processus  vaginalis  to  close.  A  path  is 


436  INJURIES  AND   TORSION  OF   THE   TESTICLE 

thereby  left  open  for  the  protrusion  of  the  abdominal  viscera.  Every 
imdescended  testis,  says  Moschkowitz,  is  accompanied  by  a  potential 
or  an  actual  hernia.  In  the  92  imdescended  testes  reported  by  Odiorne 
and  Simmons,  hernia  was  present  in  49  (57  per  cent.).  Of  these,  10 
were  strangulated.  In  some  cases  the  hernia  occupies  a  separate  sac, 
or  the  hernial  sac  may  invaginate  the  tunica  vaginalis  as  it  blocks  the 
inguinal  canal.  A  hernia  of  such  a  type  is  doubtless  brought  about  by 
the  dilatation  of  the  inguinal  canal  caused  by  the  retained  testicle.  The 
testicle  may  act  as  a  ball  valve  and  bring  about  strangulation  of  the 
hernia  or  may  block  its  progress  through  the  canal  and  force  it  to 
burrow  out  between  the  muscular  layers. 

Diagnosis. — The  differential  diagnosis  between  strangulation  of  a 
hernia  accompanying  an  imdescended  testis  and  acute  epididymitis  or 
torsion  of  the  testicle  itself  may  be  difficult,  particularly  in  the  first 
twenty-four  hours.  A  strangulated  hernia  is  less  painful  locally  but 
more  disturbing  generally;  the  vomiting  is  more  persistent,  the  tem- 
perature normal  or  subnormal;  the  abdomen  increasingly  distended. 
Torsion  of  an  undescended  testicle  is  most  painful  at  first,  the  pain 
decreasing  after  a  few  hours.  There  may  be  nausea,  but  the  vomiting 
is  not  so  marked  a  feature.  The  temperature  is  normal  or  slightly 
elevated.  Locally,  the  tenderness  is  intense,  the  swelling  only  moder- 
ate in  degree.  The  overlying  skin  may  be  reddened.  Clear  urine  and 
a  negative  history  of  urethritis  favor  both  these  diseases,  whereas  the 
presence  of  a  urethral  infection  would  make  one  strongly  suspicious  of 
acute  epididymitis.  If  epididymitis  is  developing,  the  temperature  is 
likely  to  be  elevated;  the  testicle  is  not  much  enlarged,  but  is  acutely 
tender.  The  overlying  skin  reflects  the  underlying  inflammation  by 
edema  and  redness.  After  the  first  twenty-four  hours,  the  epididymis 
may  be  differentiated  from  the  testicle. 

Whichever  diagnosis  is  arrived  at,  there  is  but  one  safe  course. 
Operation  at  once  is  indicated,  not  only  to  relieve  the  possible  strangu- 
lated hernia,  but  to  prevent  the  infection  which  may  develop  in  torsion 
or  in  epididymitis  from  spreading  to  the  peritoneal  cavity  through  the 
hernial  sac  which  is  almost  always  present. 

Treatment  of  Undescended  Testicle. — To  recapitulate  briefly,  the  unde- 
scended testicle  if  left  alone  is  almost  sure  to  cease  functionating;  it  is 
liable  to  injury,  to  torsion,  perhaps  to  tumor  growth.  The  chances  are 
more  than  even  that  sooner  or  later  a  hernia  will  develop.  In  very 
young  children  the  descent  of  the  testis  may  be  encouraged  by  gentle 
massage  above  and  behind  the  gland  (Langenbeck).  The  use  of  a 
forked  truss  is  not  advised  by  Moschkowitz.  If  the  testis  does  not 
descend  of  its  own  accord,  operation  is  indicated. 

Age  at  Operation. — Most  writers  on  this  subject  are  agreed  that  opera- 
tion before  the  age  of  three  is  contra-indicated  by  smallness  of  the  parts 
and  the  difficulty  in  keeping  the  child  dry.  As  to  the  time  of  election 
for  operation,  there  is  a  diversity  of  opinion.  Moschkowitz  does 
not  operate  on  children  under  three  years.  Bevan  thinks  from  six 
to  twelve  years  is  the  best  time;  Eccles,  from  six  to  eight  years. 


IMPERFECT  DESCENT  OF  THE  TESTICLE  437 

Ope  rail  re.  Treatment. — In  the  history  of  operative  treatment  of  un- 
descended  testicle  three  operations  appear — orchidectomy,  reposition  of 
the  organ  within  the  abdomen,  and  orchidopexy,  or  the  placing  of  the 
testicle  within  the  scrotum.  Today  the  only  indications  for  orchid- 
ectomy are  the  presence  of  neoplasm  or  of  such  injury  to  the  testicle 
through  gangrene,  inflammation  or  fibrous  change  as  to  render  it  worth- 
less or  dangerous  to  the  individual.  Reposition  of  the  testes  within  the 
abdomen  is  bad  surgery.  Their  function  will  be  destroyed,  and  if  any 
of  the  accidents  to  which  the  testicle  is  liable  should  befall  them,  they 
are  inaccessible.  The  only  justifiable  operation  for  an  otherwise  healthy 
retained  testicle  is  orchidopexy,  and  every  undescended  testicle  which 
can  be  palpated  should,  according  to  Bevan,4  be  so  treated.  Even 
infra-abdominal  testes,  provided  they  give  symptoms,  should  be  brought 
into  the  scrotum.  The  first  operation  for  this  purpose  was  described  by 
Schiiller41  in  1881.  He  advised  closing  off  the  processus  vaginalis  to 
make  a  tunica  vaginalis,  repair  of  the  accompanying  hernia  and  suture 
of  the  testis  to  the  bottom  of  the  scrotum.  Various  modifications  of 
this  operation  were  suggested,  the  innovation  usually  consisting  of  a 
new  method  of  anchoring  the  testicle  in  the  scrotum.30  None  of  these 
was  generally  successful,  however.  The  testicle  would  retract.  It  re- 
mained for  A.  1).  Bevan,3  in  1899,  to  suggest  an  operation  which  would 
give  the  three  essentials — namely,  a  viable  testis,  the  permanent  estab- 
lishment of  that  testis  well  down  in  the  scrotum,  and  the  repair  of  the 
accompanying  hernia. 

Bevan  pointed  out  that  the  structure  which  prevented  the  placing  of 
the  testicle  in  the  scrotum  was  not  the  vas  deferens,  but  was  the  sper- 
matic cord.  lie  therefore  lengthened  this  cord  as  much  as  possible  by 
separating  the  adhesions  between  its  loops  and  by  freeing  it  from  the 
peritoneum  of  the  lateral  and  posterior  walls  of  the  abdominal  cavity. 
If  it  was  still  too  short  he  cut  it,  leaving  the  testicle  to  draw  its  blood 
supply  from  the  deferential  artery.  As  has  been  shown  by  Picque  and 
Worms  and  by  other  observers,  there  is  a  constant  anastomosis  between 
the  spermatic,  the  deferential,  and  the  funicular  arteries,  so  that  divi- 
sion of  any  one  of  these  three  is  compatible  with  the  life  of  the  testicle. 
Moschkowitz  ligated  the  spermatic  vessels  in  dogs  and  examined  the 
testes  from  four  days  to  three  weeks  after  ligation.  The  testes  removed 
a  few  days  after  ligation  showed  some  necrosis  of  the  interior,  but  a  fair 
state  of  preservation  around  the  periphery.  The  ones  removed  later 
showed  no  important  lesion.  Bevan 's  operation  has  now  been  done 
many  times  with  good  results  (Moschkowitz,  Ochsner,33  Bevan)  in 
marked  contrast  to  the  results  obtained  by  the  earlier  operations 
(Odiorne  and  Simmons,  Broche5). 

A  recent  paper  by  C.  G.  Mixter,26  reporting  end-results  in  cases  of 
undescended  testicle  operated  at  the  Children's  Hospital,  Boston, 
puts  this  operation  in  rather  a  different  light.  Of  9  cases  in  which  the 
spermatic  cord  had  been  severed,  7  reported,  and  in  every  case  the 
testicle  showed  marked  atrophy.  In  14  cases  in  which  no  spermatic 
vessels  were  cut,  no  testicles  were  atrophied.  Three  cases  in  which  the 


438 


INJURIES  AND   TORSION  OF  THE  TESTICLE 


spermatic  vessels  were  cut  had  undescended  testicles  on  the  other  side ; 
Mixter  says  "in  every  case  the  testicle  was  atrophied  on  the  side 
where  the  vessels  were  cut,  while  where  the  vessels  were  left  intact  the 
testicle  developed  normally." 

It  is  our  feeling,  therefore,  that  the  ligation  and  division  of  the 
spermatic  cord  should  be  avoided,  as  it  is  almost  certain  to  result  in 
atrophy  of  the  testicle.  The  other  points  to  which  Bevan  calls  atten- 
tion, particularly  the  stripping  of  the  peritoneum  off  the  cord,  are 
important. 

The  steps  of  the  operation  are  as  follows4  (Figs.  192  to  204). 

If  the  gland  is  palpable,  make  an  incision  three  inches  long  over  the 
inguinal  canal.  Do  not  carry  the  incision  below  the  external  inguinal 
ring.  Open  the  canal.  Divide  the  cremasteric  and  transversalis 
fasciae.  Open  the  processus  vaginalis.  Divide  the  sac  at  its  neck,  and 


FIG.  192. — Undescended  testicle.     (Bevan.) 

free  the  peritoneal  portion  from  the  spermatic  cord.  Close  the  lower 
portion  of  the  processus  vaginalis*  around  the  spermatic  cord  by  means 
of  a  purse-string  suture,  to  form  a  tunica  vaginalis.  Draw  down  on  the 
cord,  meanwhile  dividing  with  tissue  forceps  the  little  bands  of  fascia 
which  bind  the  loops  of  the  vessels  together.  With  one  finger  in  the 
abdominal  cavity,  free  the  spermatic  vessels  from  the  posterior  surface 
of  the  peritoneum.  Distend  the  scrotum  with  the  fingers,  and  place  the 
testicle  therein.  If  the  spermatic  cord  is  still  too  short  it  may  be 
divided  between  ligatures.  If  this  is  done  the  vas  and  its  artery  must 
be  handled  with  particular  care,  since  the  blood  supply  of  the  testis 
depends  upon  their  integrity.  After  the  testis  is  placed  in  the  scrotum 
a  purse-string  suture  is  taken  through  the  neck  of  the  scrotum  in  front  of 

*  Closure  of  the  processus  vaginalis  around  the  spermatic  cord,  as  advised  by  Bevan, 
is  almost  certain  to  produce  a  hydrocele. — Editor. 


IMPERFECT  DESCENT  OF  THE  TESTICLE 


439 


the  vessels.     The  suture  should  pass  through  the  superficial  fascia  and 
the  pillars  of  the  external  inguinal  ring  as  well. 


Skin 

\      Superficial  fascia 

•      ;     External  oblique  divided 


Stoi 


Superficial  fascia 
External  oblique 
Crcmasteric  fascia 


FIG.  193 


FIG.  194 


External  oMiqiie 
•    Crmastericfiiscia divided 


Point  at  iv/iich  vaginal  process 

should  be  divided 
Vaginal  process  open,  cxpos- 
'          testicle 


FIG.  195  FIG.  196 

FIGS.  193  to  196.— Undescended  testicle.     (Bevan.) 

The  neck  of  the  hernial  sac  is  then  closed  and  the  conjoined  tendon 
sutured  to  Poupart's  Ligament  in  front  of  the  cord.  The  aponeurosis 
of  the  external  oblique  and  the  skin  are  closed  in  the  usual  way. 

A  few  minor  changes  from  this  operation  have  been  suggested. 
Moschkowitz  removes  the  parietal  portion  of  the  processus  vaginalis 


440 


INJURIES  AND   TORXIOX   OF   THE   TEST  1  ('!.!•: 


instead  of  using  it  to  make  a  tunica.     Davison9  divides  the  deep  epi- 
gastric artery  and  the  floor  of  the  inguinal  canal,  thereby  bringing  the 


Vagbialp7vccs$  cut  acwss 

aibove  festirle 


Vaginal  process  I/ 

Purse  string  suture  to  form  a 
tunica  vaalner//'* 


Meatag  pecfart 

i/t  rry/tt  side  o 


FIG.  199  FIG.  200 

FIGS.  197  to  200. — Undescended  testicle.      (Bevan.) 

spermatic  vessels  to  the  external  inguinal  ring  in  a  more  direct  line  than 
if  they  had  to  pass  through  the  internal  inguinal  ring. 

Wolf er52 divides  the  transversalis  fascia  as  far  as  the  pubes,  lifts  up  the 
epigastric  artery  and  vein,  brings  the  testis  down  behind  the  latter,  and 
by  stripping  the  spermatic  cord  off  the  bulge  of  the  peritoneum,  he 


IMTERFECT   DESCENT  OF    THE 


441 


materially  shortens  its  course.  Moschkowitz  mentioned  a  procedure 
similar  to  this  in  1910,  and  declared  it  to  be  an  "unnecessary  and 
bothersome  refinement." 


Skin 

\     Superficial  fascia 
\     \       Exfernc/l  obliyi/e 


Conjoir/tft 


firrsi  sfn't/ff  sitfurr 
/•cft/wi'/fff  tcstfch  •/// 

///e  sera/urn 
\Jesticle  re/>7accrf  ' 


Superficial  fascia 
.Stin 


FIG.  201 


FIG.  202 


//'.Spermatic  vessels 
// '   Vas  defere?ts  &  vessels 


FIG.  203 


FIG.  2.04 


FIGS.  201  to  204.  —  Undescended  testicle.      (Bevan.) 

Orchidopexy  in  the  case  of  ectopic  testes  is  usually  made  easy  by  the 
fact  that  the  spermatic  cord  is  already  of  sufficient  length.  It  is  de- 
sirable to  obliterate  the  old  bed  of  the  testicle;  otherwise  recurrence 
may  take  place. 


442  INJURIES  AND   TORSION  OF  THE  TESTICLE 

INJURIES  OF  THE  TESTICLE. 

Luxation  or  Dislocation  of  the  Testicle. — Luxation  or  dislocation  of 
the  testicle  is  usually  the  result  of  an  accident,  such  as  the  passage  of  a 
wagon  wheel  across  the  pelvis.  The  testicle  may  be  driven  over  the 
pubes  or  toward  the  anterosuperior  spine  of  the  ilium.  Guiteras11 
records  a  case  in  which  the  testicle  was  torn  loose  from  the  body  and 
tail  of  the  epididymis  and  was  driven  out  of  the  scrotum  and  under  the 
skin  on  the  side  of  the  penis.  A  review  of  the  literature  by  Nicolas,32  in 
1899,  disclosed  3  cases  in  which  the  testis  had  been  driven  onto  the  side 
of  the  penis,  3  in  which  it  had  been  driven  over  the  pubis  and  2  in  which 
it  was  forced  into  the  groin.  Nicolas  says  that  unless  the  testis  is 
replaced,  it  undergoes  atrophy.  Summerhayes44  reported  a  case  in 
which  the  testicle  was  extruded  through  a  rent  in  the  scrotum  by  a 
blow  from  a  log  of  wood. 

Hematocele. — Hematocele  is  a  frequent  accompaniment  of  injuries 
of  the  testicle.  The  tunica  fills  with  blood,  which  clots  and  forms  a 
tender,  solid-feeling  tumor,  which  does  not  transmit  light.  Later  on, 
this  will  liquefy  and  become  a  dark  brown,  oily-looking  fluid,  or  will  be 
entirely  absorbed.  From  an  injury  of  less  severity,  traumatic  hydrocele 
may  result.  Hydroceles  of  this  origin  are  only  temporary.  Severe 
injuries  of  the  testicle  itself  are  not  met  with  very  frequently.  The  fact 
that  the  testes  lie  in  a  movable  bed,  between  the  fleshy  parts  of  the 
thighs,  saves  them  from  many  a  crushing  blow.  The  most  frequent 
type  of  injury  is  that  sustained  by  falling  astride  some  hard  object,  such 
as  a  fence.  In  such  cases  the  testicles  are  caught  between  the  hard 
object  and  the  bony  pelvis. 

Terrillon  and  Suchard,45  in  experimental  work  on  dogs,  showed  that 
punctured  wounds  and  foreign  bodies  in  the  testicle  caused  only  local 
disturbance.  Slight  blows  upon  the  fixed  testicle  caused  only  a  feeble 
reaction.  More  severe  blows  caused  reaction  in  both  testis  and  epididy- 
mis, more  marked  in  the  latter.  The  epididymal  canals  were  dilated, 
the  cilia  of  the  epithelium  was  lost,  and  the  epithelium  was  thickened 
in  places  by  the  accumulation  of  new  cells.  Injuries  of  still  greater 
degree  caused  the  formation  of  fibrin  in  the  tunica,  and  in  the  testis  the 
degeneration  of  peripheral  tubules  and  an  inflammatory  reaction  in  the 
interstitial  tissue.  Terrillon  and  Suchard  thought  this  inflammation 
would  result  later  in  the  formation  of  scar  tissue  and  the  consequent 
atrophy  of  the  testis.  Injuries  of  the  most  severe  type  caused  rupture 
of  the  tunica  alhuginea.  The  testicle  contained  ecchymotic  areas  and 
wras  of  a  yellowish-red  color;  the  epididymis  was  swollen  and  ecchy- 
motic, and  examination  of  microscopic  preparations  showed  prolifera- 
tion in  the  interstitial  tissues  as  well  as  in  the  canals. 

Terrillon  and  Suchard  conclude  that  changes  are  more  marked  in  the 
epididymis  than  in  the  testis.  In  the  former,  the  epithelium  is  chiefly 
involved;  in  the  latter,  the  interstitial  tissue.  The  subsidence  of  the 
interstitial  reaction  is  likely  to  cause  scar  formation  with  resulting 
atrophy  of  the  testicle. 


TORSION  OF  THE   TESTICLE  443 

The  treatment  consists  of  rest,  elevation  of  the  scrotum  and  the 
application  of. ice. 

TORSION  OP  THE  TESTICLE. 

Incidence. — Torsion  is  probably  more  frequent  than  would  appear 
from  the  cases  reported.  Without  doubt  a  number  of  cases  are  thought 
to  be  orchitis  or  epididymitis,  and  if  they  quiet  down,  the  diagnosis  is 
never  made.  From  1840,  when  the  first  case  was  reported,  to  1901 
Scudder42  collected  31  instances  from  the  literature  and  added  1.  In 
1907  Rigby  and  Howard39  collected  40  cases. 

Age. — Torsion  may  occur  at  any  age.  It  has  been  reported  in  a  new- 
born child  and  in  a  man  aged  sixty-two  years.  It  is  chiefly  a  disease  of 
adolescence.  Of  Scudder's  series  of  32  cases,  75  per  cent,  were  under 
twenty-four  years  of  age ;  20  of  the  32  were  between  the  ages  of  thirteen 
and  twenty-three  years. 

Cause. — That  torsion  is  due  primarily  to  some  anatomical  abnormal- 
ity is  indicated  by  the  fact  that  of  Scudder's  32  cases  of  torsion,  47 
per  cent,  were  of  undescended  testicles.  A  number  of  those  who  have 
reported  cases  have  mentioned  finding  some  anomaly,  such  as  an 
unusually  long  mesorchium. 

The  predisposing  factors  which  have  been  found  associated  with 
torsion  of  the  undescended  testis  are  given  on  page  435.  In  connec- 
tion with  fully  descended  testicles,  Rigby  and  Howard  mention  the 
following  anomalies: 

1.  Abnormal  attachment  of  the  common  mesentery  and  vessels  to 
the  lower  pole  of  the  testis  and  to  the  globus  minor,  so  that  the  testis  is 
attached  by  a  narrow  stalk  instead  of  by  a  broad  band. 

2.  Elongation  of  the  globus  minor. 

3.  Capacious  tunica  vaginalis. 

The  exciting  cause  may  be  exercise  or  violent  straining,  but  2  cases 
are  reported  by  Rigby  and  Howard  in  which  torsion  occurred  during 
sleep.  In  a  case  recently  operated  at  the  Massachusetts  General 
Hospital  the  torsion  came  on  during  sleep.  A  case  of  recurrent  torsion 
has  been  recorded47  in  which  the  patient  learned  to  untwist  the  torsion 
himself. 

Pathology. — Upon  opening  the  tunica,  more  or  less  bloody  fluid  is 
evacuated;  the  testis  and  epididymis  appear  swollen,  indurated  and 
almost  black  in  color.  The  spermatic  cord  is  thrombosed  below  the 
twist,  normal  above.  The  twist  may  consist  of  from  one-half  a  turn  to 
four  half-turns,  in  either  direction.  The  cut  surface  of  the  testicle 
resembles  blood  clot.  Hemorrhagic  infarction  may  occur,  or  hemor- 
rhage between  the  lobules  (Scudder).  In  one  of  Rigby  and  Howard's 
cases,  microscopic  examination  showed  no  normal  testicular  cells. 
Later  stages  of  the  lesion  will  show  atrophy,  more  or  less  complete,  or 
sloughing.  The  latter  is  more  liable  to  occur  if  hernia  coexists,  Rigby 
and  Howard  believe,  as  the  bacteria  of  the  intestine  are  thus  brought 
nearer  to  the  devitalized  testis. 


444  IXJfh'IES   AXD    TORSI  OX   OF    THE    TESTICLE 

Symptoms. — Severe,  sudden  pain  in  the  testicle,  sufficient  to  cause 
slight  shock  with  nausea  and  vomiting,  occurs  at  the  time  of  the  twist. 
Not  infrequently  this  occurs  at  night.  The  temperature  may  rise 
slightly.  The  skin  over  the  affected  testicle  becomes  edematous  and 
red.  Differentiation  between  the  testicle  and  epididymis  on  palpation 


FIG.  205. — Gangrene  of  the  testicle  due  to  torsion  of  the  cord.  The  testicle  and  epi- 
didymis were  gangrenous  from  a  point  just  above  the  epididymis.  Testicle  and  epi- 
didymis considerably  enlarged  from  edema.  There  were  areas  of  hemorrhage  and 
beginning  necrosis  on  the  surface  and  in  the  interior  of  the  organs.  There  was  associated 
hydrocele  of  the  cord  (A)  dependent  upon  the  strangulation  of  the  cord.  (Scudder.) 

is  lost.  At  first  the  tumor  is  exquisitely  sensitive;  after  a  few  days  the 
acute  tenderness  subsides,  but  tenderness  on  pressure  may  persist  for 
weeks. 

Diagnosis. — In  the  case  of  torsion  of  the  undescended  testis  the 
condition  most  difficult  to  differentiate  is  strangulated  hernia.  (See 
page  436.)  With  the  testicle  fully  descended,  hernia  is  more  easily 


TORSION  OF   THE   TESTICLE  445 

excluded.  To  diagnose  the  case  as  acute  epididymitis  is  the  most 
usual  mistake.  In  the  early  hours  of  epididymitis,  before  the  epi- 
didymis  shows  much  swelling,  the  physical  signs  are  indeed  similar. 
The  sudden  onset  of  an  "  epididymitis"  in  a  boy  or  youth  who  shows  no 
evidence  of  urethra!  infection  is  strongly  suggestive  of  torsion.  Epi- 
didymitis is  seldom  so  excruciatingly  tender  during  its  inception. 

Treatment. — If  the  case  is  seen  within  the  first  hour  or  two,  an  at- 
tempt may  be  made  to  untwist  the  cord.  The  testis  is  supported  by  one 
hand  and  gently  rotated  with  the  other.  As  one  cannot  be  sure  of  the 
direction  in  which  the  testicle  has  turned,  this  measure  does  not  offer 
much  hope.  It  was  done  successfully  by  Nash31  one  hour  after  the 
onset,  but  atrophy  subsequently  occurred.  When  torsion  occurs  in  an 
undescended  testicle  the  gland  should  be  removed  promptly  to  avoid 
the  possibility  of  peritonitis.  With  fully  descended  testes  expectant 
treatment  may  be  employed.  The  patient  should  be  kept  in  bed,  the 
scrotum  elevated,  and  ice  applied.  Kigby  and  Howard  followed  this 
treatment  in  4  cases.  Two  of  the  testes  atrophied  very  little;  one 
disappeared  altogether;  none  sloughed.  The  operative  reduction  of 
the  torsion  with  suturing  of  the  testicle  to  prevent  recurrence  has 
always  resulted  in  atrophy  and  seems  to  offer  no  better  chances  for 
preserving  the  testicle.  It  seems  justifiable  to  try  the  expectant  method 
for  a  few  days,  as  even  an  atrophied  testicle  means  more  to  the  patient 
than  none  at  all.  If,  however,  the  symptoms  do  not  speedily  subside, 
or  if  tenderness  of  the  testicle  persists,  orchidectomy  should  be  done. 


BIBLIOGRAPHY. 

1.  Beigel:  Virchows  Archiv,  xvii,  S.  144. 

2.  Berg:  Ann.  of  Surg.,  August,  1904. 

3.  Bevan:  Jour.  Am.  Med.  Assn.,  1899,  xxxiii,  773-775. 

4.  Bevan:  Jour.  Am.  Med.  Assn.,  September  19,  1903,  xli,  718-723 

5.  Broche:  Quoted  by  .Odiorne  and  Simmons. 

6.  Cruveilhier:  Traite  d'Anat.  Path.  Gen.,  vol.  i,  p.  301. 

7.  Cunningham:  Text-book  of  Anat.,  1903,  p.  849. 

8.  Cunningham:  Text-book  of  Anat.,  1903,  p.  1104. 

9.  Davison:  Surg.,  Gynec.  and  Obst.,   1911,  xii,  283-288. 

10.  Ec-oles:  The  Imperfectly  Descended  Testis,  New  York,  1903,  pp.  10-12. 

11.  Guiteras:  Med.  Rec.,  1896,  xlix,  11-13. 

12.  Halstead:  Surg.,  Gynec.  and  Obst.,  1907,  iv,  129-132. 

13.  Hancs:  Jour.  Exp.  Med.,  1911,  iii,  338-354. 

14.  Hanes  and  Rosenbloom:  Jour.  Exp.  Med.,  1911,  iii,  335-364. 

15.  Hem  pel:  Ueber  Ektopia  Testis,  8°,  Kiel,  1911. 

16.  Howell:  Am.  Text-book  of  Physiology,  1901,  ii,  445. 

17.  Jacobson:  Diseases  of  the  Male  Organs  of  Generation,  1893. 

18.  Jordan:  Deut.  Med.  Wchnschr.,  1895,  xxi,  525. 

19.  Lamb:  Proc.  of  the  Am.  Assn.  of  Anat.,  1896,  pp.  47-60. 

20.  Lane:  Brit.  Med.  Jour.,  1894,  ii,  1241. 

21.  Lenhossek:  Anatomischer  Anzeiger,  1845. 

22.  Lenhossek:  Quoted  by  Halstead:  Surg.,  Gynec.  and  Obst.,  1907,  iv,  129-132. 

23.  Lewis  and  Stohr:  A  Text-book  of  Histology,  1914,  p.  344. 

24.  Lewis  and  Stohr:  A  Text-book  of  Histology,  1914,  pp.  335-341. 

25.  Marshall:  Edinburgh  Med.  and  Surg.  Jour.,  1828,  xxx,  172. 

26.  Mixter:   Undescended  Testicle  in  Children,  Boston  Med.  find  Surg.  Jour.,  1916, 
Ixxv,  No.  18,  p.  63. 

27.  Monod  and  Terrillon:  Maladies  du  Testicule,  1879,  p.  46. 


44()  INJURIES  AND  TORSION  OF   THE   TESTICLE 

28.  Morris:  Human  Anatomy,  5th  edition,  p.  610. 

29.  Morris:  Human  Anatomy,  5th  edition,  p.  744. 

30.  Moschkowitz:  Ann.  of  Surg.,  1910,  vii.  821-835. 

31.  Nash:  Brit.  Med.  Jour.,  1893,  i,  742. 

32.  Nicolas:  These  de  Paris,  1899. 

33.  Ochsner:  Jour.  Am.  Med.  Assn.,  September  19,  1903,  xli,  723. 

34.  Odiorne  and  Simmons:  Ann.  of  Surg.,  1904,  xi,  962-1004. 

35.  Pappenheim  and  Schwartz:  New  York  State  Jour.  Med.,  1910,  No.  12,  p.  548. 

36.  Popow:  Bull,  de  la  Soc.  Anat.,  1888,  p.  653. 

37.  Poupart:  Un  Type  Nouveau  d'Ectopie  Testiculare,  These  de  Paris,  1897. 

38.  Picque  and  Worms:  Jour,  de  1'Anat.,  1909,  xlv,  No.  1,  pp.  51-64. 

39.  Rigby  and  Howard:  Lancet,  1907,  i,  1416. 

40.  Rigby  and  Howard:  Torsion  of  the  Testes,  Lancet,  1907,  i,  1415-1421. 

41.  Schiiller:  Zent.  f.  Chir.,  1881. 

42.  Scudder:  Ann.  of  Surg.,  1901,  xxxiv,  234  24s. 

43.  Smith,  G.  B.:  Guy's  Hosp.  Rep.,  1896,  liii,  215-240. 

44.  Summerhayes:  Brit.   Med.  Jour.,   1896,  ii,   1036. 

45.  Terrillon  and  Suchard:  Arch,  de  Phys.  normale  et  pathologique,  Paris,  1882,  2  S., 
ix,  325-335. 

46.  These  de  Paris,  1897. 

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48.  von  Bardeleben:  Verhandlungen   der  anatomischen   Gesellschaft;   Anatomischer 
Anzeiger,  1892,  vii. 

49.  von  Ebner:  Kollikers  Handbuch  der  Gewebelehre  des  Menschen,  6th  edition,  iii, 
pt.  2,  451.     Leipzig,  1902. 

.'0.  Whitehead:  Am.  Jour.  Anat.,  1904,  iii,  167-182. 

51.  Whitehead:  Anat.  Record,  1908,  ii,  177-182. 

52.  Wolfer:  Surg.,  Gynec.  and  Obst.,  1915,  pp.  228-231. 


CHAPTER   XIII. 
DISEASES  OF  THE  SCROTUM. 

BY  A.  RAYMOND  STEVENS,  M.D. 

THE  most  common  pathological  lesions  of  the  scrotum  are  those 
inflammatory  conditions  secondary  to  diseases  of  the  testicles,  the 
urethra,  and  the  rectum.  These  scrotal  complications  will  be  dealt 
with  in  their  appropriate  connections  in  the  sections  devoted  to  the 
above-named  primary  seats  of  infections. 

ANATOMY  OF  THE  SCROTUM. 

The  scrotum  is  a  loose  pouch  of  skin  investing  the  testicles  and  part  of 
the  spermatic  cords.  It  varies  markedly  in  size  in  different  individuals, 
and  with  changing  conditions  in  the  same  individual.  In  debilitated 
persons  and  the  aged  and  from  the  effect  of  heat  it  relaxes  and  becomes 
pendulous;  in  the  robust  and  the  young  and  under  the  influence  of  cold, 
emotion,  and  exercise  it  is  contracted  and  thicker.  The  layers  are  skin, 
dartos,  and  loose  areolar  tissue. 

The  Skin. — The  skin  of  the  scrotum  is  thin,  semitransparent,  and 
elastic,  is  darker  in  color  here  than  elsewhere,  and  has  a  sparse  growth 
of  hair.  It  contains  in  the  derma  many  sebaceous  and  sweat  glands. 
Superficially  its  epidermis  is  similar  microscopically  to  that  over  the  rest 
of  the  body.  Below  this  is  the  derma,  rich  in  elastic  fibers  and  involun- 
tary muscle.  The  surface  of  the  skin  is  divided  into  lateral  halves  by  a 
slight  median  ridge,  extending  from  the  penis  to  the  margin  of  the  anus. 
From  this,  on  either  side,  extend  rugse  with  a  generally  horizontal 
arrangement,  determined  by  muscular  fibers  in  the  derma,  parallel  to 
the  surface  and  running,  as  a  rule,  transversely. 

Dartos. — The  dartos  is  immediately  beneath  the  skin  and  intimately 
associated  therewith.  But  contrary  to  the  statement  of  some  anato- 
mists, it  can  be  dissected  from  the  skin.  The  line  of  cleavage  is  proved 
microscopically  to  be  between  the  muscle  layer  of  the  derma  and  that  of 
the  dartos.  The  dartos  is  a  reddish-brown  stratum,  best  developed  in 
front  and  at  the  sides,  continuous  with  the  suspensory  ligament  of  the 
penis  and  the  superficial  fascia  of  the  abdomen,  groin  and  perineum, 
and  at  the  sides  is  attached  to  the  ischiopubic  rami.  It  is  the  con- 
tractile portion  of  the  scrotum,  containing  connective  tissue,  elastic 
fibers,  and  considerable  unstriped  muscle,  the  fibers  of  which  are 
placed  at  right  angles  to  those  of  the  derma.  It  is  very  vascular  and 
entirely  free  from  fat.  The  dartos  forms  two  sacs,  for  the  correspond- 
ing testes,  and  these  unite  in  the  median  line  to  form  the  septum  scroti. 

(447) 


448 


DISEASES  OF   THE  SCROTUM 


Areolar  Tissue. — Beneath  the  dartos  is  a  very  loose  thin  bed  of 
vascular  areolar  tissue,  continuous  with  Colles's  fascia  behind  and  the 
deep  fascia  of  the  abdomen  in  front.  Scrotal  hematomata  are  com- 
monly situated  here. 

Bloodvessels. — The  arteries  supplying  the  scrotum  are  the  external 
pudics  (from  the  femoral  arteries)  and  the  superficial  perinea!  branch  of 
the  internal  pudic.  The  reins  accompanying  the  arteries  empty  into 
the  saphenous  and  internal  pudic  veins. 

The  lymphatics  of  the  scrotum  all  terminate  in  the  inguinal  and 
femoral  glands.  The  observations  of  Morley  would  seem  to  show 


FIG.   206. — Diagramatic  section  of  scrotai  wall. 

a  free  anastomosis  of  the  lymphatics  of  the  two  halves  of  the  scrotum,  a 
free  communication  of  these  with  the  lymphatics  of  the  penis,  and  to 
a  less  extent  with  those  of  the  thighs  and  perineum.  The  fine  network 
between  the  skin  and  dartos  empty  into  lymph  trunks  which  dip  at  once 
through  the  dartos.  There  are  ten  to  twenty  main  trunks  on  either 
side,  which  course  toward  the  inguinal  glands.  It  is  surgically  interest- 
ing that  the  uppermost  ones  may  curve  up  1  to  2.5  cm.  on  the  side  of  the 
penis,  thence  run  1  cm.  above  the  pubic  spine,  parallel  to  Poupart's 
ligament,  ending  in  a  gland  sometimes  only  4  cm.  from  the  anterior 
superior  spine.  No  collecting  trunks  are  found  to  accompany  the 
internal  pudic  vessels;  and  there  apparently  is  no  connection  between 


INJURIES  OF  THE  SCROTUM  449 

the  lymphatics  of  the  scrotum  and  those  of  the  tunica  vaginalis  and 
testicles. 

Nerves. — The  nerves  supplying  sensation  to  the  scrotum  are  branches 
of  the  ilio-inguinal,  superficial  perinea!  branches  of  the  pudic  nerve,  the 
inferior  pudendal  (from  the  small  sciatic),  and  the  genital  branch  of 
the  genitocrural.  The  sympathetic  nerves  accompanying  the  vessels 
supply  the  muscle  fibers  of  the  dartos. 

ABNORMALITIES  OF  THE  SCROTUM. 

The  half  of  the  scrotum  corresponding  to  an  undescended  testicle*  is 
frequently  rudimentary.  In  pseudohermaphroditism  the  scrotum  is 
cleft,  the  halves  resembling  labia  majora.  Partial  cleft  scrotum  may 
accompany  congenital  defects  elsewhere  in  the  genito-urinary  system, 
e.  g.,  abnormalities  of  the  penis  and  urethra,  and  ectopia  vesicse. 

Abnormal  pigmentation  of  the  scrotum  may  be  mentioned  here 
to  note  that  the  pigment  granules  are  placed  histologically  in  the  same 
location  as  those  normally  found — that  is,  in  the  deepest  cells  of  the 
epidermis. 

INJURIES  OF  THE  SCROTUM. 

Stab,  puncture,  and  gunshot  wounds  are  subject  to  the  same  surgical 
consideration  as  similar  injuries  elsewhere.  Growing  hematomata 
should  be  freely  incised,  clots  removed,  and  bleeding-points  ligated. 
Free  drainage  must  be  established  in  the  presence  of  infection  or  an 
injury  to  the  urethra. 

Hematoma. — Hematoma  without  rupture  of  the  cutaneous  surface 
is  common,  and  is  easily  produced  by  blows  upon  the  scrotum.  It  is 
important  to  .differentiate  hematocele  and  hemorrhage  within  the 
testicle  from  hematoma  in  the  substance  of  the  scrota!  wall ;  the  former 
frequently  requires  operation  while  the  latter  rarely  does,  but  is  best 
treated  by  rest,  elevation,  and  cold  applications,  with  perhaps  a  com- 
pression bandage. 

Loss  of  Substance. — Loss  of  substance  from  accident  or  attempts 
at  emasculation  may  lead  to  serious  bleeding.  Control  of  hemorrhage 
is  of  first  importance,  then  surgical  cleanliness  and  subsequent  aseptic 
dressing.  The  reparative  power  of  the  scrotum  is  amazing.  After  the 
loss  of  over  two-thirds  of  this  tissue,  leaving  the  testicles  exposed  and 
dangling,  it  is  quite  possible  for  nature  to  repair  this  vast  rent  and 
restore  a  satisfactory  scrotum,  without  surgical  interference.  So  that 
one  method  of  treatment  after  all  hemorrhage  is  controlled  is  merely  to 
keep  the  raw  area  covered  with  a  mildly  antiseptic  dressing.  However, 
the  course  of  such  repair  is  slow  and  may  be  further  <  prolonged  by 
active  fungous  outgrowth  of  granulations  from  the  testicles,  necessitat- 
ing application  of  the  actual  cautery.  Better  results  in  extensive 
injuries  and  a  shorter  convalescence  are  obtained  by  surgery.  By 
loosening  the  skin  of  the  inner  and  anterior  aspects  of  the  thighs,  flaps 
may  be  cut  with  horizontal  sides,  and  with  the  externally  placed 

M  u     i — 29 


450  DISEASES  OF  THE  SCROTUM 

attachments  broader  than  the  free  end.  These  when  sewed  together 
will  easily  cover  the  testicles  and  form  an  adequate  sac.  In  some 
cases,  after  loosening  the  skin  from  underlying  tissues  over  a  wider 
area,  including  the  perineum,  the  edges  may  be  apposed  without  actual 
flap  formation,  and  with  ultimately  good  results.  If  only  the  anterior 
wall  of  the  scrotum  is  wanting  the  simplest  procedure  is  to  draw  upward 
the  remaining  portion  of  the  sac  and  suture  it  to  the  upper  skin  margin. 
Should  the  skin  of  the  base  of  the  penis  also  be  trimmed  away  the  penis 
may  be  pushed  under  that  part  of  the  scrotum  drawn  forward  and 
brought  out  at  a  lower  level.  Subsequently  flaps  of  skin  from  the  lateral 
aspects  of  the  scrotum  are  used  to  cover  any  raw  surface  on  the  penis. 
Suture  of  the  Scrotum. — As  already  stated,  the  dartos  is  closely 
attached  to  the  skin,  and  its  muscular  fibers  are  generally  at  right 
angles  to  those  in  the  skin.  This  explains  the  tendency  of  the  skin 
edges  to  curl  in  regardless  of  the  direction  of  the  incision.  Approxima- 
tion of  the  skin  does  not  necessarily  include  the  dartos  and  areolar  layer, 
and  subsequently  bleeding  from  this  very  vascular  region  may  occur, 
forming  a  large  hematoma.  This  may  be  guarded  against  by  employ- 
ing hemostatic  sutures.  Each  is  applied  about  1  cm.  from  the  margins 
of  the  wound,  penetrating  both  layers  of  the  skin  and  dartos,  and 
returning  in  the  reverse  direction  1  cm.  apart,  the  knot  is  tied  on  the 
side  first  entered.  Subsequently  a  line  of  continuous  sutures  accurately 
approximates  the.  skin  edges;  or  both  objects  may  be  attained  in  a  very 
practical  way  by  one  line  of  sutures,  interrupted  or  continuous,  applied 
about  0.5  cm.  from  the  margins  of  the  wound  and  taking  each  time  a  good 
bite  of  the  deeper  structures.  By  another  method,  using  interrupted 
sutures,  each  stitch  is.  carried  one  way  through  both  skin  and  deeper 
structures,  and  returning  takes  only  a  small  bite  of  skin.  Obviously, 
the  knot  is  tied  on  the  side  first  penetrated  by  the  needle. 

CUTANEOUS  DISEASES  OF  THE  SCROTUM. 

Cutaneous  diseases  will  be  dealt  with  very  briefly.  Fuller  discus- 
sions are  readily  found  in  works  on  dermatology. 

Erythema  Intertrigo  (Chafing). — Erythema  intertrigo  affects  the 
lateral  and  posterior  aspects  of  the  scrotum.  It  may  occur  at  any  age, 
but  more  commonly  in  children  and  fat  individuals.  Uncleanliness, 
wetness  (urine  or  perspiration),  and  friction  in  walking  are  the  three 
chief  etiological  factors.  The  treatment  is  simple;  cleanliness,  dry- 
ness,  the  use  of  a  dusting  powder,  and  a  suspensory  with  perhaps  some 
padding  of  cotton.  Dermatitis  or  eczema  may  develop,  requiring 
appropriate  lotions  or  ointments. 

Eczema  Simplex. — Eczema  simplex  is  said  to  be  more  frequently  met 
with  in  persons  of  rheumatic  or  gouty  diathesis.  Its  common  seat  is 
the  lateral  and  posterior  aspects  of  the  scrotum.  The  lesions  and 
symptoms  are  those  of  eczema  in  other  parts  of  the  body.  Treatment 
in  milder  cases  consists  simply  of  support  of  the  scrotum,  avoidance  of 
friction,  and  application  of  a  dusting  powder,  such  as  the  oxide  or  stear- 


CUTANEOUS  DISEASES  OF   THE  SCROTUM  451 

ate  of  zinc.  Itching  is  relieved  by  2  to  4  per  cent,  carbolic  acid  applied 
alone  on  gauze  or  incorporated  in  some  simple  lotion  or  ointment. 

Eczema  Marginatum.— Erythema  marginatum  is  ringworm  modified 
by  erythema  or  eczema  intertrigo,  and,  indeed,  the  parasitic  nature  of 
the  affection  may  be  obscured  by  these  accompaniments.  It  occurs 
on  the  moist  regions  of  the  scrotum  in  patches,  which  present  well- 
defined  margins  and  elevated  borders  and  characteristic  central  healing 
and  peripheral  advance.  Treatment  should  be  directed  first  to  any 
associated  erythema  or  eczema.  Subsequently  the  affected  spots  are 
painted  on  several  occasions  with  tincture  of  iodine;  or  unguentum 
hydrargyri  ammoniati  is  well  rubbed  in  daily  and  the  applications 
continued  some  days  after  an  apparent  cure. 

Pityriasis  Versicolor. — Pityriasis  versicolor  occurs  as  yellowish- 
brown  spots  or  patches  on  the  scrotum,  and  is  caused  here  as  elsewhere 
by  a  vegetable  parasite,  Microsporon  furfur,  which  attacks  clean  as 
well  as  dirty  skins.  There  may  be  mild  itching  but  often  no  symptoms 
exist.  This  vegetable  growth  may  be  made  to  disappear  by  daily 
scrubbing  with  soap  and  water  followed  by  application  of  25  per  cent, 
aqueous  solution  of  sodium  hyposulphite.  Recurrence  is  frequent. 

Pediculi  Pubis. — Pediculi  pubis  are  sometimes  found  about  the 
hair  of  the  scrotum,  usually  in  association  with  a  similar  occupation  of 
the  hair  of  the  pubic  region.  The  ova  ("  nits")  are  tightly  attached  to 
the  hairs  and  their  presence  is  as  pathognomonic  as  the  parasite.  An 
eczema  may  coexist  in  the  uncared-for  cases.  The  parasite  and  their 
ova  are  easily  killed  by  unguentum  hydrarg.,  by  1  to  1000  solution  of 
bichloride  of  mercury,  by  kerosene,  or  the  tincture  of  larkspur.  In 
patients  harboring  a  large  colony,  and  especially  in  uncleanly  indivi- 
duals, it  is  advisable  first  to  shave  all  hair  from  the  parts. 

Scabies. — Scabies  is  carried  to  the  genitalia  by  the  hands.  The 
characteristic  "  burrows"  of  the  parasite  of  scabies,  Acarus  scabiei,  may 
be  seen.  Numerous  punctate  abrasions  and  excoriated  papules  and  a 
few  crusts  are  often  found.  Itching,  most  marked  at  night,  is  almost 
invariably  present.  Treatment  is  simple  and  effective:  a  warm  bath, 
sulphur  ointment  rubbed  over  all  affected  regions  morning  and  night 
for  several  days,  followed  by  another  bath  and  a  change  to  fresh  clothes. 
A  second  course  of  treatment  may  be  required,  if  a  bland  lotion  or  oint- 
ment does  not  clear  up  the  skin  in  a  few  days. 

Syphilis. — Syphilis  of  the  scrotum  is  common,  most  frequently  seen 
as  papules,  which  on  the  moist  surfaces  become  macerated  and  abraded. 
If  untreated,  they  may  develop  papillary  outgrowths,  forming  warty  or 
cauliflower-like  excrescences  (condylomata).  I  Iceroserpiginous  lesions 
may  develop  here,  and  less  frequently  gummata  or  single  ragged  ulcers. 
The  occasional  development  of  chancre  of  the  scrotum  must  be  empha- 
sized. Only  cleanliness  is  necessary  locally  if  the  intensive  constitu- 
tional treatment  of  syphilis  be  instituted. 

Lupus. — Lupus  of  the  scrotum  is  comparatively  rare. 

Pruritus. — Pruritus  occurs  with  some  of  the  above  diseases  and 
also  without  demonstrable  skin  lesions.  The  latter  cases  have  fre- 
quently some  constitutional  debility,  as  gout,  rheumatism,  or  diabetes. 


452  DISEASES  OF   THE  SCROTUM 

Treatment  is  often  most  unsatisfactory  except  as  affording  temporary- 
relief.  One  must  first  institute  dietetic  and  hygienic  measures  aimed  at 
fundamental  constitutional  disorders.  Tonics  or  alkalies  may  be 
indicated.  Turkish  baths  are  sometimes  beneficial.  Locally,  thymol, 
'  weak  carbolic  acid,  or  menthol  in  lotions  or  ointments  and  sometimes 
hot  water  relieve  the  symptoms  temporarily. 

Sebaceous  Cysts  or  Steatoma. — These  are  formed,  as  elsewhere  on 
the  skin,  from  sebaceous  glands  dilated  by  retained  secretion.  Small 
palpable  cysts  of  the  scrotum  are  present  in  many  individuals,  and  not 
infrequently  isolated  ones  attain  a  diameter  of  5  to  10  mm.  Single 
cysts  may  occur  anywhere  on  the  scrotum;  large  groups  are  more  com- 
monly found  on  the  anterior  aspect.  They  are  yellowish,  rounded,  and 
firm,  within  (not  under)  the  skin,  the  larger  ones  protruding  externally. 
They  cause  no  symptoms  unless  infected;  then  they  are  tender  and  the 
surrounding  skin  is  reddened.  Xo  treatment  is  indicated  except  for 
cosmetic  results  or  for  inflammation.  They  may  be  excised  under  local 
anesthesia;  or  incised,  the  contents  evacuated,  and  the  sac  destroyed  by 
curetting,  or  by  cauterization — easily  done  with  pure  carbolic  acid. 

Varicose  Veins. — The  veins  of  the  scrotum  may  show  marked  vari- 
cosity,  which  has  been  confused  with  varicose  veins  of  the  pampiniform 
plexus.  This  should  not  occur  if  careful  palpation  is  made.  However, 
the  two  conditions  frequently  occur  together.  Small  telangiectatic 
spots  may  accompany  the  varicosity.  Usually  no  treatment  is  needed. 
Bruyneel1  reported  an  instance  of  spontaneous  rupture  of  varicose  veins 
of  the  scrotum,  with  loss  of  about  200  c.c.  of  blood,  in  a  man  of  seventy- 
seven  years.  It  is  conceivable  that  the  size  of  the  mass  may  be  a  source 
of  annoyance.  The  veins  are  largest  in  lax,  elongated  scroti  and  the 
easiest  treatment  is  excision  of  the  skin  area  most  involved  and  its  con- 
tained veins,  careful  hemostasis  by  ligature  and  proper  placing  of  deep 
skin  sutures. 

INFLAMMATION  OF  THE  SCROTUM. 

Edema. — Edema  may  be  secondary  to  severe  anemia  and  to  organic 
disease  of  the  heart,  kidneys,  or  liver,  and  is  then  often  part  of  a  general 
anasarca.  It  may  be  due  to  mechanical  pressure  on  veins  or  lymphatics 
draining  the  scrotal  tissues,  or  edema  may  be  inflammatory  in  origin, 
from  infection  of  the  testicles,  perineum,  groins,  or  scrotal  wall.  In 
every  case  the  treatment  should  be  directed  to  the  primary  trouble.  In 
the  edemas  of  systemic  causation  and  those  due  to  mechanical  pressure, 
rarely  are  any  local  measures  indicated  other  than  support  by  strap- 
ping or  a  suspensory,  cleanliness,  and  dryness  of  the  skin.  It  is  un- 
usual that  tension  develops  sufficiently  to  endanger  the  vitality  of 
the  skin.  When  it  does  so  a  few  punctures  may  be  made  in  the  skin  and 
the  parts  kept  covered  with  a  sterile  wet  dressing,  and  every  care  taken 
to  prevent  infection. 

Cellulitis  and  Abscess.  —  Cellulitis  and  abscess  are  in  the  vast 
majority  of  cases  secondary  to  inflammation  of  deeper  structures,  but 
may  be  due  to  infection  of  the  scrotum  per  se.  Cold,  wet  applications 


INFLAMMATION  OF  THE  SCROTUM  453 

and  support  of  the  parts  will  suffice  for  milder  infections.  Severe 
cellulitis  and  abscess  require  incision  and  drainage. 

Erysipelas. — Erysipelas  is  most  frequent  in  old  or  debilitated  indi- 
viduals. The  onset  is  announced  with  a  chill,  high  fever,  and  malaise. 
Locally  a  bright  red  spot  develops  and  gradually  spreads  over  part  or  all 
of  the  scrotum.  The  latter  swells  markedly,  is  sometimes  covered  with 
blebs,  and  may  finally  become  gangrenous.  On  the  other  hand  (and 
usually),  there  may  be  complete  resolution  and  a  return  to  normal. 
The  constitutional  symptoms  are  those  of  erysipelas  elsewhere.  Also 
the  bacteria  found  here  are  the  same  as  those  causing  the  disease  in 
other  locations.  It  is  worthy  of  note  that  in  some  cases  resembling 
erysipelas  of  the  scrotum  clinically  the  Klebs-Loeffler  bacillus  has  been 
cultivated  from  the  wound  discharge.  The  treatment,  general  and 
local,  is  similar  to  that  of  erysipelas  in  other  regions,  remembering 
always  to  keep  the  scrotum  elevated.  Numerous  local  applications 
have  had  a  period  of  popularity.  Cold  compresses  wet  with  boric 
acid  solution  are  as  satisfactory  as  any  local  treatment. 

Gangrene. — Gangrene  of  the  scrotum  may  be  due  to  infection  of 
deeper  structures  (urethra  or  testicles),  through  vascular  obstruction 
and  bacterial  invasion  of  the  scrotal  wall;  to  primary  scrotal  infection 
(e.  g.,  erysipelas);  to  mechanical  or  chemical  or  thermal  injury;  to 
trophic  disturbances;  and  to  systemic  conditions  acting  as  primary  or 
predisposing  causes  (diabetes,  cardiovascular  and  renal  diseases,  al- 
coholism, general  debility).  Gangrene  may  be  made  of  rarer  occur- 
rence by  aseptic  care  of  wounds,  free  incision  (not  too  long  delayed), 
timely  surgical  treatment  of  the  deeper  inflammations,  and  pains- 
taking care  of  the  medical  conditions  mentioned  above.  Treat- 
ment is  logically  at  once  directed  to  the  underlying  causative 
factors.  Locally,  incision  through  the  dartos  is  to  be  made,  and  all 
definitely  gangrenous  tissue  excised.  Aseptic  dressings  are  changed  fre- 
quently until  all  evidence  of  active  inflammation  has  disappeared.  The 
testicles  are  never  involved  secondarily,  and  if  the  loss  of  substance 
has  been  great,  are  left  freely  exposed.  Left  to  Nature,  those  large 
gaping  wounds  will  heal  fairly  rapidly  and  with  finally  satisfactory 
results.  But  in  many  instances,  a  quicker  convalescence  may  be  had  by 
some  plastic  operation  (noted  under  Injuries). 

Emphysema. — Emphysema  is  seen  in  connection  with  general  sub- 
cutaneous emphysema,  sometimes  with  scrotal  gangrene  or  wounds  in 
which  gas-producing  organisms  are  present.  Treatment  is  multiple 
incision  and  free  drainage  in  the  infected  cases.  When  an  anaerobic 
organism  is  the  offender,  frequent  irrigation  with  hydrogen  peroxide 
should  be  done. 

Ulcerating  or  Sclerosing  or  Serpiginous  Granuloma  of  the  Pudenda.— 
This  is  a  disease  of  the  tropics,  occurring  especially  in  the  dark  races,  and 
generally  contracted  through  sexual  relations.  It  usually  starts  on  the 
penis,  as  a  nodular  elevation  of  skin,  very  vascular  and  prone  to  break 
down  and  bleed.  It  extends  very  slowly  by  peripheral  advance  or  by 
auto-infection  of  neighboring  skin,  especially  in  moist  areas.  The 
scrotum  is  often  involved,  showing  a  dense,  uneven  white  or  pigmented 


454 


DISEASES  OF  THE  SCROTUM 


scar  within  the  serpiginous,  raised  periphery.  The  thighs  and  anal  region 
may  be  involved.  The  lymph  glands  are  not  infected;  the  general 
health  is  good.  It  resembles  lupus  vulgaris  somewhat,  but  is  found  only 
about  the  genitalia.  The  etiology  is  not  determined.  Treatment  is 
unsatisfactory  unless  the  case  be  seen  early  enough  for  excision. 

Calculi. — Calculi  of  the  scrotum  have  been  described.  They  are 
calcified  hematomata,  true  urinary  calculi  which  have  ulcerated  through 
from  the  urethra,  or  the  remnants  of  calcareous  deposits  in  old  urinary 
fistulse. 


FIG.  207. — Solid  form  of  elephantiasis.     (Charles.) 

ELEPHANTIASIS  (FILARIAL)   OF  THE  SCROTUM. 

The  term  elephantiasis  arabum  is  used  to  describe  large  diffuse 
enlargements  of  the  scrotum,  consisting  of  hard  edema  and  hyperplasia 
of  both  the  skin  and  connective  tissue.  While  it  is  comparatively 
common  in  certain  tropical  countries,  in  the  localities  favorable  for 
breeding  of  mosquitoes,  it  is  rare  in  colder  climates,  and  most  of  the 
patients  seen  have  resided  in  the  tropics.  It  is  particularly  prevalent 
in  Samoa  and  Huahine. 

Etiology. — The  observations  and  deductions  of  competent  students 
of  elephantiasis  are  convincing  in  ascribing  this  condition,  in  at  least 
the  majority  of  cases,  primarily  to  a  nematode,  known  as  Filaria  san- 


ELEPHANTIASIS  OF  THE  SCROTUM  455 

guinis  hominis  (or  Filaria  nocturna,  or  Filaria  bancrofti).  This  is  one 
of  five  or  six  filaria?  found  in  man,  and  one  of  the  two  of  these  which  are 
pathogenic.  The  larval  forms  frequently  found  in  the  blood  are  trans- 
parent, colorless,  and  cylindrical,  0.3  mm.  long  and  about  the  diameter 
of  a  red  blood  corpuscle.  In  a  fresh  specimen  the  larvae  wiggle  within 
encasing  sheaths  without  changing  position  on  the  slide.  They  are  in 
the  peripheral  blood  only  at  night,  mostly  at  midnight,  the  time  of 
greatest  activity  of  the  mosquito.  This  periodicity  may  be  reversed 
by  having  the  patient  sleep  in  the  daytime.  During  their  absence 
from  the  peripheral  vessels,  the  larvae  are  in  the  larger  arteries,  the 
lungs,  and  to  a  less  extent  in  the  heart  muscle.  Several  observers  have 
described  a  parasite,  morphologically  the  same  as  Filaria  bancrofti, 
present  in  peripheral  blood  in  the  daytime  as  well  as  nighttime.  But 
this  is  not  the  rule. 

The  complete  life-cycle  involves  two  hosts,  man  and  certain  mos- 
quitoes (Manson  mentions  eight  species  which  may  serve  as  inter- 
mediate hosts).  The  mosquito,  feeding  on  the  blood  of  an  infected 
individual,  takes  in  the  larval  form  of  filaria;  these  escape  from  their 
sheaths  in  the  mosquito's  stomach,  and  then  acquire  locomotion;  they 
enter  the  thoracic  muscles,  and  in  the  next  twelve  to  twenty  days  in- 
crease in  size  and  develop  an  alimentary  canal  and  other  parts;  the 
majority  reach  the  proboscis  of  the  mosquito  and  are  usually  arranged 
in  pairs.  The  mosquito  now  is  capable  of  infecting  human  beings 
when  feeding  on  their  blood  and  possibly  through  drinking  water  when 
dying  in  the  same.  In  man  the  filarise  soon  reach  the  lymphatics, 
attain  sexual  maturity,  and  pour  larvae  into  the  lymph,  thence  to  the 
blood.  The  adult  worms  are  hair-like,  transparent,  and  4  to  9  cm.  long, 
the  female  longer  than  the  male.  The  sexes  live  together,  often  in- 
extricably coiled  in  lymphatics,  lymph  varices  or  glands. 

Filarial  disease  does  its  chief  harm  through  obstruction  of  lymphatic 
vessels.  This  may  be  caused  by  the  adult  worm,  alive  or  cretified, 
acting  as  a  plug,  inducing  thrombus  formation,  or  inciting  inflammatory 
thickening  of  the  vessel  wall  and  consequent  narrowing  of  its  lumen. 
The  microfilarise  (larvae)  have  no  known  pathological  effect,  but  ova 
have  been  found  in  the  lymph,  and  as  they  are  incapable  of  traversing 
lymph  glands,  it  seems  quite  possible  that  lymph  stasis  may  sometimes 
be  caused  by  ova  being  lodged  in  the  glands. 

Pathology. — The  immediate  results  of  obstruction  are  lymphatic 
varicosities  or  edema,  or  both.  These  conditions  are  most  common  for 
obvious  reasons  on  the  lower  extremities.  The  scrotum  is  involved  next 
in  frequency.  Lymph  varicosities  of  the  scrotal  wall  cause  a  moderate 
or  greater  enlargement  called  lymph  scrotum.  The  skin  is  soft  and 
silky  and  on  inspection  presents  evident  varices.  Microfilariae  are 
usually  present  in  the  lymph  locally.  Often  the  inguinal  and  femoral 
glands  are  enlarged.  Erysipelatous  inflammation  is  a  frequent  com- 
plication. Lymph  scrotum  may  remain  such  or  become  elephan- 
tiasis, which  is  the  combined  result  of  lymph  stasis  and  recurrent 
inflammation.  Lymph  stasis  alone  causes  varices  and  edema  only. 
The  sequence  of  events  is  lymph  stasis  (from  causes  already  given), 


-loli  DISEASES  OF   THE  SCROTUM 

lymphangitis,  imperfect  absorption  of  the  inflammatory  products,  and 
gradual,  intermittent,  progressive,  inflammatory  hypertrophy.  The 
derma  is  dense,  fibrous,  and  enormously  hypertrophied.  The  con- 
nective tissue  is  increased  in  bulk  and  has  a  blubbery  appearance;  on 
section  there  is  a  free  oozing  of  lymph.  Bloodvessels  are  enlarged  and 
lymphatics  dilated. 

Symptoms. — Beginning  as  edema  or  lymph  scrotum  the  scrotum  is 
only  a  little  enlarged.  Attacks  of  lymphangitis  with  cellulitis  and  fever 
may  occur.  After  this  subsides  the  parts  do  not  return  quite  to  nor- 
mal. Increased  edema  and  recurrent  lymphangitis  lead  to  greater 
enlargement.  The  scrotum  in  typical  elephantiasis  may  weigh  200 
pounds  (one  of  224  pounds  is  recorded).  The  mass  is  pyriform  in 
shape;  a  transverse  section  of  the  upper  part  is  triangular  with  the 
apex  toward  the  anus.  The  skin  is  leathery,  rough  and  coarse,  and  pits 
little,  if  at  all.  It  is  thickest  at  the  bottom,  thinnest  at  the  top,  and  thin 
and  soft  at  the  sides  and  posteriorly.  It  gradually  merges  all  around 
into  the  healthy  skin.  Mouths  of  follicles  are  sometimes  very  distinct; 
the  hair  is  coarse  and  sparse.  The  penis  is  at  the  upper  and  anterior 
part,  at  the  bottom  of  a  channel  formed  by  the  foreskin  and  skin  of  the 
penis  dragged  inside  out  by  the  enlargement  of  the  scrotum.  The 
testes  are  usually  in  the  posterior  part  of  the  mass,  nearer  the  bottom 
than  top,  each  held  there  by  its  hypertrophied  gubernaculum  testis. 
The  spermatic  cords  are  thickened  and  very  long,  and  hydroceles  are 
usually  present.  The  tumor  may  grow  rapidly  or  slowly;  may  become 
enormous  in  two  or  three  years  or  may  never  grow  large.  An  attack  of 
lymphangitis  may  intervene,  causing  painful  cord-like  swellings  of 
lymph  trunks  and  glands,  with  redness  of  the  overlying  skin,  chill  and 
high  fever,  headache,  perhaps  vomiting,  and  sometimes  delirium. 

The  general  health  may  be  excellent  except  during  the  attacks  of 
inflammation.  The  scrotum  is  cumbersome  and  unsightly  and  sexual 
relations  become  impossible.  Gangrene  may  supervene;  abscesses 
sometimes  form;  eczema  or  ulcerations  may  occur;  and  varices  may 
rupture,  allowing  escape  of  lymph. 

Axxociatcd  conditions  due  to  filariasis  are  orchitis;  hydrocele;  lymph- 
angitis; abscess;  varicose  glands;  arthritis;  synovitis;  elephantiasis 
and  lymph  varices  elsewhere,  especially  in  the  legs;  chyluria,  chylocele, 
chylous  ascites,  and  chylous  diarrhea  caused  by  rupture  of  varicose 
lymphatics  in  the  urinary  tract,  tunica  vaginalis,  peritoneum  and 
intestinal  tract. 

Diagnosis. — The  larval  forms  of  the  Filaria  sanguinis  hominis  are 
commonly  present  in  the  lymph  of  the  varices  of  lymph  scrotum,  arid 
may  be  found  in  the  blood.  Because  the  adult  worms  have  usually 
died,  it  is  rare  to  find  microfilariae  in  the  blood  in  elephantiasis.  Indeed, 
in  filarial  countries  a  smaller  percentage  of  people  with  elephantiasis 
than  of  those  without  elephantiasis  have  these  parasites  in  the  blood. 
However,  they  should  be  looked  for  microscopically,  using  thick  prepa- 
rations made  at  night.  These  may  be  studied  fresh,  or  after  being  dried 
and  stained  (without  fixing)  for  one  hour  in  weak  carbol-fuchsin  (4 
drops  of  saturated  alcoholic  solution  to  one  ounce  of  water).  In  some 


ELEPHANTIASIS  OF  THE  SCROTUM  457 

cases  the  blood  shows  an  eosinophilia,  and  with  the  acute  conditions 
a  leukocytosis.  An  associated  lymphangitis,  with  its  constitutional 
symptoms,  is  suggestive.  A  history  of  residence  in  tropical  or  sub- 
tropical climates  is  generally  elicited. 

Lymph  stasis  due  to  other  causes  may  give  the  picture  of  lymph 
scrotum  and  an  added  inflammation  may  cause  an  actual  elephantiasis. 
However,  the  scrotal  condition  would  be  accompanied  or  even  over- 
shadowed by  other  symptoms,  which,  with  the  history,  would  lead  to  a 
correct  diagnosis  of  syphilis,  pyogenic  infection,  or  mechanical  obstruc- 
tion of  the  lymphatics. 

Prophylaxis. — The  life-cycle  of  the  Filaria  bancrofti  can  be  completed 
in  neither  man  nor  mosquito,  but  only  by  passage  of  the  parasite  from 
one  to  the  other.  One  human  being  cannot  contract  filarial  disease 
from  another,  but  becomes  infected  only  by  the  form  of  the  parasite 
developed  in  the  mosquito.  Prevention  of  filariasis  and  its  many  con- 
sequences hinges  on  the  elimination  of  the  mosquito.  Its  breeding 
places  should  be  dealt  with  according  to  methods  now  generally  known 
in  civilized  communities.  Individuals  harboring  filarise  and  all  unin- 
fected  people  in  tropical  climates  should  be  carefully  protected  from 
mosquitoes.  It  is  possible,  though  not  proved,  that  water  to  which 
mosquitoes  have  had  access  may  convey  the  parasite.  Hence  all  drink- 
ing water  in  the  tropics  should  be  boiled. 

Treatment. — While  simple  lymphatic  edema  may  subside  it  seems 
generally  recognized  that  lymph  scrotum  and  elephantiasis  do  not 
recover  spontaneously.  They  remain  stationary  for  years  or  recede 
somewhat  in  bulk  after  an  attack  of  lymphangitis,  but  such  scrota 
never  again  become  normal. 

The  cure  of  filariasis  involves  the  destruction  of  the  adult  parasites. 
Xo  known  drug  is  efficient  to  this  end.  The  worms  often  die  after 
plugging  a  lymph  trunk,  especially  after  lymphangitis,  and  thus  a  spon- 
taneous cure  of  the  active  infection  may  occur.  But  the  numerous 
sequelae  of  the  obstruction  remain.  When  the  site  of  the  entrapped 
worm  is  surgically  accessible,  operation  may  really  cure  the  disease. 
But  the  location  of  the  parasite  cannot  often  be  diagnosed  during  life. 
When  scrotal  involvement  is  the  only  sign  of  filariasis  it  seems  probable 
that  the  worm  is  in  the  inguinal  glands.  Primrose16  reported  a  case 
cured  clinically  and  according  to  blood  examination  by  surgical  removal 
of  part  of  the  scrotum  in  which  the  adult  worm  was  found.  Cunningham5 
operated  for  elephantiasis,  did  not  find  any  filaria  in  the  specimen  re- 
moved, but  larval  forms  were  found  in  the  blood  before  operation  and 
none  afterward ;  the  patient  was  clinically  well  at  the  end  of  twenty 
months  when  the  case  was  reported  and  has  remained  well  since. 

Lymph  scrotum  should  be  kept  clean  and  dry  and  a  well-fitting  sus- 
pensory worn.  Chyluria  and  elephantiasis  of  the  leg  have  followed  sur- 
gical intervention.  If  anything  is  attempted,  a  complete  excision  is  the 
best  procedure. 

Lymphangitis  and  fever  are  treated  by  confining  the  patient  to  bed, 
elevating  the  scrotum,  and  applying  ice-bags  or,  better,  cold  compresses. 
Morphine  may  be  necessary  to  relieve  pain.  The  bowels  are  kept  open, 
light  diet  given,  and  a  copious  quantity  of  water  should  be  taken. 


458  DISEASES  OF  THE  SCROTUM 

Elephantiasis  of  the  scrotum,  if  small  and  not  burdensome,  had  better 
be  merely  guarded  against  injury,  or  perhaps  bandaged  tightly.  If 
large,  excision  is  not  only  feasible  but  advisable.  In  parts  of  India  this 
is  one  of  the  commonest  of  operations.  One  surgeon  reports  having 
removed  "over  a  ton"  of  scrota!  The  immediate  and  remote  results 
are  good  as  regards  comfort  and  sightliness  and  the  patient's  working 
efficiency.  Attacks  of  fever  often  cease  after  operation.  Coitus  and 
procreation  become  possible.  The  general  mortality  of  the  operation  is 
a  trifle  over  5  per  cent.  Charles/  Maitland,11  Murray15  and  Calvert3  have 
reported  (totaling  their  cases)  560  operations  of  excision  of  the  scrotum 
for  elephantiasis  with  only  6  deaths.  Charles  had  a  series  of  140 
consecutive  unselected  cases  without  a  death  and  Calvert  a  series 
of  151. 

The  operation  is  preceded  if  possible  by  elevation  of  the  scrotum 
(sometimes  with  compression  as  well)  and  frequent  cleansing  for  two  or 
three  days.  Erosions  or  ulcerations  of  the  skin  should  be  healed  before 
operation.  The  usual  preoperative  preliminaries  of  examination  and 
preparation  are  to  be  observed.  The  patient  is  placed  in  the  lithotomy 
position.  A  figure-of-eight  tourniquet  (around  waist  and  base  of  scrotum) 
may  be  used  to  control  bleeding;  some  operators  of  large  experience 
advise  against  it.  The  incisions  outlining  the  tissue  to  be  removed  must 
all  be  made  in  healthy  skin.  Three  primary  incisions  are  made:  one  in 
the  median  line  from  near  the  pubis  to  the  preputial  orifice,  through 
which  the  penis  is  freed  by  the  finger,  and  two  over  the  cords,  and  far 
enough  into  the  scrotum  to  permit  of  liberating  the  testicles,  cutting  of 
the  gubernaculi,  and  delivery  from  the  wound  of  cords  and  testicles. 
Then  follows  the  complete  excision,  of  the  diseased  tissue.  Care  is 
needed  to  avoid  the  dorsal  vein  of  the  penis,  and  also  the  bulb  of  the 
urethra,  which  is  pulled  downward  by  the  mass.  Hemorrhage  is  con- 
trolled more  by  torsion  than  by  ligature.  The  skin  of  the  inner  aspects 
of  the  thighs  is  dissected  free  and  the  two  edges  sewed  together  after 
placing  the  testicles  on  the  perineum  beneath  the  flaps  thus  obtained. 
Perineal  drainage  is  employed.  The  skin  about  the  penis  is  sutured  to 
the  tunica  albuginea  (not  the  connective  tissue)  while  the  penis  is  held 
extended,  avoiding  suturing  over  the  urethra.  If  the  foreskin  be  the 
least  involved,  trim  it  off  close  to  the  glans  penis.  If  healthy,  save  it 
and  stitch  to  the  tunica  albuginea.  The  raw  surface  of  the  penis  is 
covered  at  once  with  Thiersch  grafts  obtained  from  the  thigh.  Hydro- 
celes  are  usually  encountered  and  are  dealt  with  by  excision  of  the  sacs. 
Varicocele  may  be  excised.  Inguinal  herniae  are  occasionally  found, 
and  are  subjected  to  radical  cure  if  the  patient's  condition  permits. 
Castration  is  advisable  if  the  testicles  are  infected  or  entirely  atrophied. 
Two  cases  of  concomitant  epithelioma  of  the  penis  have  been  reported 
in  the  literature.  This  condition  would  necessitate,  in  addition  to  the 
scrotal  operation,  amputation  of  the  penis  and  careful  dissection  of 
the  inguinal  groups  of  glands. 

The  knees  are  kept  tied  together   for  some  days  after  operation. 
Annoying  erections  are  best  controlled  by  an  ice-bag. 

Wise  and  Minett12  in  enumerating  the  situations  where  adult  filarise, 


NEOPLASMS  OF  THE  SCROTUM 


459 


alive  or  cretified,  have  been  found,  report  them  in  the  inguinal  glands  in 
25  cases.  This  would  make  it  appear  wise  to  remove  the  inguinal 
glands  of  patients  who  are  in  good  condition  if  there  be  larvae  present 
in  the  blood  before  operation  and  elephantiasis  of  the  scrotum  is  the 
only  other  evidence  of  filariasis. 

Kondoleon8  has  recently  advised  in  cases  of  edema  of  the  scrotum 
and  early  elephantiasis,  incision  of  the  skin  over  both  testicles,  excision 
of  a  strip  of  fascia  3  or  4  cm.  broad,  incision  and  turning  back  of  the 
tunicse  vaginalis  as  for  hydrocele.  and  suture  of  the  skin  without 
drainage. 

Castellani12  has  recommended  daily  injections  of  2  c.c.  fibrolysin  for 
fibromatosis  of  the  legs.  But  there  would  appear  little  use  for  this 
method  in  the  scrotum,  where  radical  operation  is  so  efficient. 

Elephantiasis  of  Non-filarial  Origin. — Elephantiasis  of  non-filarial 
origin  represents  sporadic  cases  of  unknown  etiology  in  patients  who 
have  not  visited  the  trop'ics.  Instances  have  been  mentioned  in  which 
the  condition  was  due  to  the  blocking  of  the  lymphatics  by  a  scar,  or  by 
infection,  or  after  operative  removal  of  the  inguinal  glands  with,  of 
course,  a  supervening  infection  in  the  scrotal  wall.  A  slight  degree 
of  elephantiasis  may  occur  with  ulcerating  granuloma  of  the  genitalia. 
A  similar  condition  is  referable  to  tertiary  syphilis  in  rare  cases.  A  con- 
vincing report  of  such  a  case  was  made  by  McDonagh;10  the  scrotum 
measured  28^  inches  in  circumference,  and  was  reduced  by  mercurial 
treatment  to  13|  inches. 


FIG.  208. — Cancer  of  the  scrotum. 


NEOPLASMS  OF  THE  SCROTUM. 

New  growths  of  the  scrotum  are  relatively  uncommon.  The  least 
uncommon  and  most  important  is  epithelioma,  known  as  chimney- 
sweep's cancer.  It  is  a  rarity  in  America  but  more  frequently  met 


M-OI'LAS.\JS  OF   THE  SCROTUM 

with  in  England.  Morley14  found  records  of  30  cases  at  the  Manchester 
Royal  Infirmary  from  1906  to  1910,  and  (for  comparison)  only  _!.">  of 
carcinoma  of  the  penis.  It  was  seen  in  former  days  chiefly  among 
chimney-sweeps,  and  nowadays  is  particularly  found  among  workers  in 
paraffin  and  other  coal-tar  products.  Butlin2  showed  years  ago  by 
very  interesting  statistical  data  that  the  irritation  of  soot  and  coal-tar 
products  was  a  marked  predisposing  etiological  factor. 

Cancer  begins  in  the  form  of  one  or  more  warts,  apparently  remaining 
benign  for  years;  or  as  a  superficial,  painful,  ragged,  vascular  ulcer  with 
hard  base  and  edges  with  a  scab  on  its  surface,  situated  usually  on  the 
lower  part  of  the  scrotum.  Pathologically  this  is  a  true  epithelioma. 
Clinically  it  is  slow  growing,  and  the  glandular  involvement  is  relatively 
late.  Metastasis  to  other  organs  is  uncommon.  If  untreated  the  growth 
may  gradually  involve  testicles,  perineum,  and  penis.  The  treatment  is 
thorough  excision  of  the  scrotum  and  enucleation  of  the  inguinal  and 
femoral  glands,  preferably  in  one  mass  (see  paragraph  on  Lymphatics 
of  the  Scrotum).  Unless  adherent  the  testicles  and  cord  should  not 
be  removed. 

Adenocarcinoma  metastasis  in  the  scrotum  has  been  reported. 
Primary  melanosarcoma  is  of  rare  occurrence.  Instances  of  angioma, 
lymphangioma,  fibroma,  lipoma,  chondroma,  osteoma,  hydatid  cyst, 
atheromatous  cyst,  and  dermoid  cyst  of  the  scrotum,  have  been  recorded. 


BIBLIOGRAPHY. 

1.  Bruyneel:  Un  cas  de  rupture  de  varices  du  scrotum,  Bull.  Soc.  de  med.  de  Gand. 
1908,  Ixxv,  106. 

2.  Butlin:  Cancer  of  the  Scrotum  in  Chimney-sweeps  and  Others,  Brit.  Med.  Jour., 
1892,  i,  1341;  ii,  1. 

3.  Calvert:  The  Operation  for  Removal  of  Elephantiasis  of  the  Scrotum  and  Penis; 
Notes  on  Two   Hundred  Consecutive  Cases,   Indian   Med.   Gaz.,   Calcutta,    1905,   xl, 
161-163. 

4.  Charles:    The  Surgical    Technic    and   Operative   Treatment  of   Elephantiasis  of 
the  Generative  Organs,  Based  on  a  Series  of   One   Hundred  and    Forty   Consecutive 
Successful  Cases,  Indian  Med.  Gaz.,  1901,  xxxvi,  <s4. 

5.  Cunningham:  Filariasis,  Ann.  Surg.,  October,  1906,  p.  481. 

6.  Daniels  and  Wilkinson:  Tropical  Medicine  and  Hygiene,  1909. 

7.  Greene:  Cancer  of  the  Scrotum,  Boston  Med.  and  Surg.  Jour.,  1910,  clxiii,  755, 
792. 

8.  Kondoleon:  Die  Lymphableitung  des  Scrotum,  Zentralbl.  f.  Chirurgie,  Leipsic, 
September  26,  1914,  xli,  No.  39,  1513. 

9.  Kuhn  and  Giihne:  Zur  operativen  Behandlung  der  Elephantiasis  Scroti,  Archiv 
f.  Schiffs.  u.  Tropen-Hyg.,  Leipzig,  1913,  xvii,  457. 

10.  McDonagh:  Case  of  Syphilitic  Elephantiasis  of  the  Scrotum,  Proc.  Roy.  Soc. 
Med.,  London,  1911-1912,  v,  Dermat.  Sect.,  67. 

11.  Maitland    The  Operation   for  Removal  of   Elephantiasis  of  the   Scrotum   and 
Penis,  Indian  Med.  Gaz.,  1901,  xxxvi,  161. 

12.  Manson:  Tropical  Diseases,  1914,  5th  edition. 

13.  Matas:  The  Surgical  Treatment  of  Elephantiasis,   etc.,   Am.   Jour.   Trop.  Dis., 
New  Orleans,  1913,  i,  60  85. 

14.  Morley:  Lymphatics  of  the  Scrotum  in  Relation  to  Radical  Operation  for  Scrotal 
Epithelioma,  Lancet,  1911,  ii,  1545. 

15.  Murray:  Elephantiasis  of  the  Scrotum  and  Penis,  Indian  Med.  Gaz.,  1902,  xxxvii, 
457. 

16.  Primrose:  Filariasis  in  Man  Cured  by  Removal  of  Adult  Worms  in  an  Operation 
for  Lymph  Scrotum,  Canada  Prac.,  Toronto,  1905,  xxx,  135-146. 

17.  Whiting:  Gangrene  of  the  Scrotum,  Ann.  Surg.,  Philadelphia,  1905,  xli,  841-862. 


CHAPTER  XIV. 

HYDROCELE,  HEMATOCELE  AND  VARICOCELE. 
BY  HENRY  L.  SANFORD,  M.D. 

HYDROCELE. 

Definition. — Hydrocele  in  its  ordinary  form  is  an  abnormal  accumula- 
tion of  serous  fluid  in  the  cavity  of  the  tunica  vaginalis.  Normally  a 
few  drops  of  fluid  are  present  between  the  visceral  and  parietal  layers  of 
the  tunica  as  a  protection  to  the  testis. 

Other  forms  of  hydrocele  represent  collections  of  fluid  contained  in 
other  structures  than  the  cavity  of  the  tunica  vaginalis,  either  com- 
municating with  it  or  distinct  from  it.  A  brief  reference  to  the  embryo- 
logical  development  of  these  structures  will  aid  in  explaining  the  origin 
of  these  other  types. 

Anatomy. — Before  its  descent  into  the  scrotum  the  testis  is  a  retro- 
peritoneal  abdominal  organ  and  has  no  direct  relation  with  the  true 
abdominal  cavity.  As  it  descends  on  the  gubernaculum  testis  it  carries 
with  it  the  anterior  covering  of  peritoneum,  which  is  to  become  the 
visceral  layer  of  the  tunica  vaginalis,  and  as  the  testis  passes  through  the 
internal  ring  and  the  inguinal  canal  it  pushes  before  it  a  pouch  of  parietal 
peritoneum  which  is  called  the  processus  funicularis,  and  which  in  turn 
becomes  the  parietal  layer  of  the  tunica  vaginalis. 

In  the  scrotum  the  visceral  layer  of  the  tunica,  after  covering  the 
testis,  passes  over  onto  the  epididymis,  which  it  includes  between  its 
two  leaves,  and  is  then  reflected  onto  the  parietal  layer  of  the  tunica. 
It  thus  happens  that  the  posterior  inner  border  of  the  testis  where  it  is 
apposed  to  the  epididymis  has  no  peritoneal  covering,  and  so  it  main- 
tains its  original  retroperitoneal  character. 

After  this  complicated  migration  of  the  testis  is  completed  a  door  is 
shut  after  it  to  hold  it  in  position.  If  this  door  does  not  close  soon  after 
birth  or,  in  other  words,  if  the  cavity  of  the  funicular  process  of  peri- 
toneum through  which  the  testis  descended  does  not  become  obliterated, 
conditions  are  present  which  admit  of  various  abnormalities.  Among 
them  are  some  of  the  types  of  hydrocele  to  be  considered. 

Varieties. — Hydroceles  may  be  classified*  according  to  their  ana- 
tomical location  into : 

1.  Hydrocele  of  the  testis. 

2.  Hydrocele  of  the  cord. 

3.  Complications  of  1  and  2. 

4.  Hydrocele  of  a  hernial  sac. 

*  Jacobson's  Classification. 

(461) 


462  HYDROCELE,  HEMATOCELE  AND  VARICOCELE 

1.  Hydroceles  of  the  testis  include  (A)  those  of  the  tunica  vaginal  is, 
where  the  fluid  -Is  in  a  sac  cfirectly  connected  with  the  tunica  vaginal  is.     Of 
these  there  are  four  forms: 

(1)  The  ordinary  type,  distending  the  closed  tunica  vaginalis; 

(2)  The  congenital  type,  where  the  sac  of  the  tunica  vaginalis  com- 
municates directly  with  the  abdominal  cavity,  due  to  complete  failure 
of  the  processus  funicularis  to  close; 

(3)  The  infantile  type,  in  which  the  sac  of  the  tunica  vaginalis  and 
a  portion  of  the  processus  funicularis  are  filled  with  fluid,  but  no  con- 
nection exists  with  the  abdominal  cavity,  representing  partial  failure  of 
closure  of  the  processus  funicularis ;  and 

(4)  The  inguinal  type,  a  hydrocele  in  relation  to  an  undescended 
testis. 

(B)  Encysted  hydroceles  of  the  testis,  in  which  the  fluid  is  in  a  sac 
distinct  from  the  tunica  vaginalis,  as  in  encysted  hydroceles  of  the  epi- 
didymis when  the  fluid  is  contained  between  the  two  layers  of  visceral 
tunica  as  it  passes  from  the  testis  over  onto  the  epididymis,  and 
encysted  hydroceles  of  the  testis,  where  the  fluid  is  between  the  tunica 
albuginea  and  the  visceral  layer  of  the  tunica.  These  are  rare  types. 

2.  Hydroceles  of  the  cord  may  be  of  the  diffused  type,  a  serous  col- 
lection of  the  nature  of  edema  in  the  cellular  tissue  of  the  cord,  or  of  the 
encysted  type,  fluid  in  a  distinct  sac  originating  either  from  some  unob- 
literated  portion  of  the  processus  funicularis,  or  from  a  cyst  formed 
independently  of  this  process,  by  dilatation  of  persistent  tubules  of  the 
organ  of  Giraldes. 

3.  Complications  of  these  forms  of  hydrocele  represent  any  two  forms 
coexisting  or  any  form  occurring  with  hernia. 

4.  Hydrocele  of  the  sac  of  a  hernia  may  occur  by  the  effusion  of  fluid 
into  a  hernial  sac,  the  contents  of  which  have  been  reduced  with  subse- 
quent obliteration  of  the  neck  of  the  sac. 

Hydroceles  may  also  be  considered  according  to  their  course  as  acute 
and  chronic,  and  as  to  their  origin  as  symptomatic  and  idiopath ic.  While 
all  idiopathic  hydroceles  are  chronic  it  is  not  equally  true  that  all 
symptomatic  hydroceles  are  acute. 

Acute  Hydrocele. — Acute  hydrocele  is  the  direct  sequel  of  inflamma- 
tion and  infection  of  the  testis  and  epididymis  and  occasionally  follows 
trauma.  The  cavity  of  the  tunica  vaginalis  is  filled  with  a  varying 
amount  of  fluid  which  may  be  serous,  fibrinous,  or  purulent.  Gonorrhea 
and  tuberculosis  of  the  epididymis  are  the  two  infections  which  most 
often  produce  symptomatic  hydrocele,  the  former  a  very  acute  type, 
the  latter  tending  to  a  more  chronic  course.  Other  causes  which  may 
produce  this  form  of  hydrocele  are  infections  by  the  pneumococcus,  the 
colon  bacillus,  by  typhoid,  erysipelas,  rheumatism,  syphilis,  and  neo- 
plastic  growths. 

Course. — The  course  of  acute  hydrocele  corresponds  to  that  of  its 
cause:  it  tends  to  recovery  as  the  primary  disease  improves  and 
becomes  chronic  as  the  cause  persists.  The  exciting  factor  may 
entirely  disappear,  however,  and  leave  behind  it  a  persistent  hydrocele. 


HYDROCELE  463 

Symptoms. — The  symptoms  of  acute  hydrocele  depend  on  the  viru- 
lency  of  the  infecting  agent.  Pain  may  be  severe  or  absent.  In  acute 
gonorrheal  epididymitis  the  tension  of  the  complicating  hydrocele  is 
often  responsible  for  a  considerable  part  of  the  severe  pain,  as  is  shown 
by  the  remarkable  relief  which  follows  the  release  of  the  fluid  in  epi- 
didymotomy.  The  hydrocele  accompanying  tuberculous  epididymitis 
on  the  contrary  rarely  causes  any  discomfort.  The  sac  of  an  acute  hydro- 
cele may  be  obliterated  by  plastic  exudate,  or  suppuration  may  occur  in  it. 

Diagnosis. — The  diagnosis  may  be  made  by  the  means  to  be  described 
under  the  chronic  type. 

Treatment. — The  treatment  is  usually  palliative.  If  the  causative 
infection  runs  a  short,  acute  course,  and  the  amount  of  fluid  is  small, 
with  rest,  elevation  of  the  scrotum  and  hot,  moist  dressings,  the  effusion 
may  be  left  to  absorb.  Severe  pain  with  considerable  fluid  demands 
aspiration,  which  may  be  repeated  if  necessary. 

Suppuration  requires  incision  and  drainage.  None  of  these  measures 
are  curative,  and  the  treatment  of  the  underlying  condition  is  the  proper 
treatment  for  the  hydrocele.  Injection  of  the  sac  is  usually  unsuccess- 
ful in  this  type  of  hydrocele,  and  should  not  be  done.  When  the  fluid 
fails  to  be  absorbed  after  some  weeks,  the  hydrocele  becomes  chronic. 

Chronic  or  Idiopathic  Hydrocele. — Etiology. — Persistence  of  an  acute 
hydrocele  is  a  common  cause  of  the  chronic  type.  This  occurs  espe- 
cially after  infections  of  the  testis  and  epididymis  which  tend  to  run  a 
chronic  course.  Cases  of  primary  disease  of  the  tunica  vaginalis  have 
been  reported  as  the  cause  of  chronic  hydrocele  without  being  secondary 
to  diseases  of  the  testis  or  epididymis.  Hildebrand4  described  a  gumma 
of  the  tunica  vaginalis  and  De  Vlaccos4  two  cases  of  tuberculosis  of  the 
tunica.  The  latter  considered  the  hydrocele  analogous  to  a  tuberculous 
ascites,  and  believes  that  the  tuberculosis  originated  in  the  abdomen, 
with  transmission  of  infection  through  an  open  processus  funicularis, 
settling  at  its  lowest  point. 

Trauma  is  considered  a  cause  of  chronic  hydrocele.  In  this  way  the 
frequent  occurrence  of  hydrocele  among  circus-riders  is  explained. 
Injuries  at  birth  have  been  held  responsible  for  certain  instances  of 
congenital  hydrocele. 

Besides  all  these  cases,  however,  to  which  an  etiological  factor  may  be 
assigned,  there  still  remain  a  large  number  of  hydroceles  the  cause  of 
which  is  not  known,  and  to  which  the  term  idiopathic  is  given.  These 
cases  are  seen  frequently  in  tropical  countries,  especially  India  and 
Egypt,  and  various  investigators  have  adduced  different  reasons  for 
their  occurrence.  Madden4  believes  this  type  s  idue  to  loose  tropical 
clothing,  which  allows  greater  trauma  to  the  testis,  and  to  oriental 
sexual  excesses,  both  of  which  tend  to  hyperemia  and  serous  exudate. 
Pfister4  thinks  there  is  a  connection  between  bilharzia  and  hydrocele, 
while  Salm4  claims  to  have  found  filarial  embryos  in  six  out  of  twelve 
East  Indian  hydroceles.  Others  have  not  confirmed  this.  Some 
chronic  irritation  of  the  local  circulation  is  believed  by  many  to  be  the 
probable  causative  factor. 


4(14 


HYDROCELE,   HEMATOCELE  AND   VARICOCELE 


Chronic  hydrocele  differs  from  varicocele  in  that  it  shows  no  predi- 
lection for  either  side,  and  it  often  is  bilateral.  All  ages  are  subject 
to  hydrocele.  Posner,21  however,  is  impressed  with  the  number  of 
hydroceles  he  has  met  with  in  old  men  in  association  with  prostatic 
hypertrophy,  and  believes  it  is  a  possible  cause  of  the  idiopathic  type. 

Pathology. — The  pathology  of  hydrocele  involves  a  study  of  the  fluid, 
the  sac,  and  the  effects,  if  any,  of  the  presence  of  the  hydrocele  on  the 
test  is  and  epididymis. 

The  Fluid. — Amount. — The  hydroceles  one  sees  today  contain  from 
4  to  10  ounces  of  fluid.  Patient,  un'ess  they  come  from  remote  dis- 
tric '  s,  rarely  allow  them  to  get  larger  without  seeking  relief.  Before  the 
days  of  surgical  asepsis,  operations  were  regarded  with  considerable 
dread,  and  cases  of  enormous  size  are  on  record.  Mursenna  (1796) 
reported  a  case  where  the  sac  measured  17  by  27  inches;  Leigh,  in  1607, 
one  where  the  tumor  weighed  120  pounds,  and  Casper,  a  case  in  which 
the  sac  held  5  gallons. 


FIG.  209. — Idiopathic  hydrocele. 


Physical  and  Chemical  Properties. — Hydroceles  in  simple  uninfected 
cases  contain  a  clear  serous  liquid  resembling  blood  serum.  It  is  of  a 
straw  or  greenish-yellow  color;  the  reaction  is  neutral;  its  specific 
gravity  varies  from  1020  to  1026,  and  it  has  no  odor.  The  fluid  is 
cloudy  if  infected,  and  may  be  brownish  red  with  a  coffee-ground 
sediment  in  case  of  old  hemorrhage.  It  contains  about  6  per  cent,  of 
albumin,  made  up  of  serum  albumin  and  globulin  with  some  fibrinogen. 
Glucose  has  been  found  in  it.  It  differs  from  ascitic  fluid  by  containing 
salts  and  fibrin.  Occasionally  on  opening  a  hydrocele  there  are  found 
in  the  fluid  fibrous  bodies  about  the  size  of  a  pea  which  are  concretions 
of  earthy  phosphates  or  carbonates  covered  with  fibrin.  Keyes15 
believes  they  probably  originate  as  deposits  of  hydrocele  salts  on  some 
warty  growth  on  the  sac  wall,  which  later  breaks  off  and  becomes  free  in 
the  fluid. 


HYDROCELE  465 

Microscopic  examination  of  the  fluid  shows  some  endothelial  cells,  a 
few  leukocytes,  cholesterin  crystals,  and  in  many  cases  spermatozoa. 
Bacteria  are  present  in  infected  cases,  and  blood  if  there  has  been  spon- 
taneous or  traumatic  hemorrhage  from  the  sac  wall  or  testis.  There  are 
often  seen  glistening  drops  which  have  been  considered  fat  drops  but 
which  Posner21  thinks  are  lipoids,  analogous  to  the  lecithin  bodies  of  the 
prostate.  He  believes  these  bodies  impart  motility  to  the  spermatozoa, 
as  does  the  lecithin  of  the  prostate.  The  presence  of  spermatozoa  is 
explained  by  the  supposition  that  a  rupture  of  semen-preparing  tubules 
has  occurred  into  the  hydrocele  sac  and  that  a  communication  between 
these  tubules  and  the  sac  must  continue  to  exist.  If  this  is  true  the 
cholesterin  crystals  found  in  hydrocele  fluid  may  be  accounted  for  as 
coming  direct  from  the  testis. 

From  Caforio's5  study  of  hydrocele  fluid  he  believes  it  to  be  an 
exudate  of  bacterial  origin  rather  than  a  transudate  from  chronic  passive 
congestion,  otherwise  he  would  expect  hydrocele  more  often  to  compli- 
cate varicocele.  and  vice  versa.  He  finds  also  that  transudates  in  gen- 
eral have  a  lower  specific  gravity  and  smaller  albumin  contents  than 
hydrocele  fluid. 

The  Sac. — The  cavity  of  the  sac  in  hydrocele  may  be  single  or  multi- 
locvlar.  Adhesions  between  the  layers  of  the  tunica  may  be  formed  as  a 
result  of  fibrinous  exudate  subsequent  to  infection  or  irritant  injections 
producing  partial  obliteration.  In  hydroceles  of  long  standing  the  sac 
wall  is  usually  much  thickened.  This  appears  especially  about  points 
of  puncture  from  previous  tapping.  Calcification  may  occur  in 
localized  areas. 

The  Testis  and  Epididymis. — Primary  disease  of  these  organs  in 
many  cases  is  the  cause  of  the  hydrocele,  but  they  may  also  suffer  as  a 
result  of  the  presence  of  the  hydrocele.  Pressure  of  the  fluid  on  the 
testis  and  thickening  of  the  connective  tissue  about  it  has  produced 
atrophy  and  loss  of  function  of  the  organ.  The  epididymis  may  also 
be  involved. 

Symptoms. — The  objective  symptoms  of  hydrocele  are  those  of  a  pear- 
shaped  tumor  of  one  or  both  sides  of  the  scrotum,  the  'arger  portion 
below,  and  the  smaller  above,  sharply  tapering  into  the  cord.  It  is 
smooth  in  outline,  elastic  to  the  touch,  dull  to  percussion,  and  trans- 
lucent to  light.  It  cannot  be  reduced  into  the  inguinal  canal,  and  gives 
no  impulse  on  coughing  unless  complicated  with  hernia.  In  hydroceles 
of  large  size  the  skin  of  the  scrotum  is  tense  and  glazed,  but  shows  no 
redness  or  edema  and  is  movable  over  the  tumor.  The  cord  leading  to 
the  hydrocele  is  normal  in  size.  The  growth  of  the  tumor  is  slow, 
enlarging  gradually  from  the  bottom  of  the  scrotum  toward  the  inguinal 
canal.  The  testis  is  usually  situated  behind  and  somewhat  below  the 
centre  of  the  tumor;  very  rarely  it  is  at  the  ront,  and  then  only  as  the 
result  of  adhesions. 

Subjectively  chronic  hydroceles  rarely  cause  any  pain  or  tenderness 
unless   some   complicating   infection   is   present.     The   fluid   gathers 
slowly  and  may  reach  some  size  before  the  patient  notices  it.     Hydro- 
M  u    i—30 


466 


HYDROCELE,   HEMATOCELE  AND   VARICOCELE 


celes  do,  however,  produce  discomfort  from  their  weight,  and  if  of  a 
large  size,  inyagination  of  the  penis  into  the  encompassing  tumor  makes 
urination  difficult  with  attendant  excoriation  of  the  skin  by  the  urine. 
Coitus  may  be  interfered  with  either  because  erections  are  poor  or 
because  the  outflow  of  semen  is  obstructed.  Cases  are  on  record  in 
which  spermatozoa  were  absent  in  the  semen  when  the  hydrocele  was 
distended,  but  reappeared  after  tapping.  Prostatics  who  have 
hydrocele  are  sometimes  hard  to  catheterize. 

Diagnosis. —  The  Light  Test. — The  property  possessed  by  simple 
hydrocele  of  transmitting  light  through  its  fluid  contents  is  the  means 
most  often  invoked  in  making  a  diagnosis.  If  the  observer  looks 
through  a  hollow  tube  held  tightly  against  one  side  of  the  hydrocele, 
while  an  electric  light  bulb  or  other  source  of  light  is  held  against  the 


FIG.  210. — Hydrooele.     Diagnosis  by  transillumination. 

opposite  side,  a  pinkish  light  will  be  seen  glowing  through  the  tumor  and 
a  darker  shadow  cast  by  the  more  solid  testis  may  sometimes  be  made 
out.  This  test  often  fails  when  the  contents  of  the  hydrocele  are 
cloudy,  when  its  walls  are  thickened,  and  in  the  presence  of  adhesions 
or  multilocular  cyst  formation.  Translucency  is  also  a  characteristic  of 
some  soft  tumors  of  the  testis  when  a  portion  of  the  contents  is  fluid ;  it 
is  observed  in  some  hernias  in  infants  and  in  some  hydatid  cysts.  This 
method  of  diagnosis  therefore  is  by  no  means  infallible. 

Unless  it  extends  up  into  the  inguinal  canal  a  hydrocele  is  sharply 
defined  at  its  upper  border,  into  which  the  cord  of  normal  size  passes. 

Puncture  of  the  hydrocele  and  recovery  of  the  typical  fluid  is  the 
surest  means  of  diagnosis.  It  should  never  be  done,  however,  unless 
the  presence  of  hernia  can  be  absolutely  ruled  out. 


HYDROCELE  467 

A  cytological  examination  of  the  aspirated  fluid  does  not  always  give 
an  idea  of  the  causative  factor  of  the  hydrocele,  but  many  authors  are 
agreed  that  the  presence  of  a  large  percentage  of  mononuclear  leuko- 
cytes is  strong  evidence  of  a  tuberculous  hydrocele. 

Besides  these  methods,  the  history  of  the  slow  gradual  development 
of  a  painless  tumor  is  of  aid  in  making  a  diagnosis. 

Differential  Diagnosis. — Hydrocele  must  be  differentiated  from  hernia, 
spermatocele,  hematocele,  chylocele,  and  solid  tumors  of  the  testis. 

Hernia  give  an  impulse  on  coughing,  is  tympanitic  to  percussion  and 
is  reducible  unless  incarcerated  or  strangulated.  In  the  latter  case  the 
previous  history  of  a  reducible  tumor  with  the  recent  acute  symptoms 
would  prevent  confusion  in  diagnosis.  It  must  always  be  remembered, 
however,  that  hydrocele  and  hernia  often  coexist,  especially  in  children. 

Spermatocele  is  differentiated  by  its  rarity,  by  the  fact  that  the  testis 
is  usually  in  front  and  belowr,  instead  of  behind  as  in  hydrocele,  and  by 
the  predominance  of  seminal  elements  in  the  fluid  contents  on  aspira- 
tion. The  differential  diagnosis  is  impossible,  however,  in  the  intra- 
vaginal  type  of  spermatocele,  which  can  only  be  identified  at  operation. 

Hematocele  can  usually  be  distinguished  by  the  recent  history  of 
injury,  by  its  solid  and  inelastic  feel,  by  the  opacity  of  its  contents,  and 
by  the  presence  of  skin  ecchymoses.  A  hydrocele  may  be  converted 
into  a  hematocele  by  spontaneous  or  traumatic  hemorrhage  from  the 
sac  wall,  the  latter  sometimes  follows  aspiration  of  a  hydrocele,  if  the 
trocar  wounds  a  vessel  in  the  sac. 

Chylocele  is  characterized  by  its  occurrence  in  the  tropics,  its  parasitic 
origin,  and  by  the  creamy  character  of  the  fluid,  which  shows  a  layer  of 
fat  at  the  top  on  settling. 

Solid  tumors  of  the  testis  differ  from  hydrocele  in  their  rapid  growth 
associated  with  pain,  in  their  non-elastic  feel,  with  absence  of  fluctua- 
tion, and  the  development  of  inguinal  glands.  There  is  frequently 
enlargement  of  the  cord  leading  to  the  growth. 

Prognosis. — In  children  cures  of  hydrocele  may  occur  spontaneously 
and  occasionally  after  a  single  tapping.  For  this  reason  certain  authors 
advise  expectant  treatment  with  children.  Other  authors  find  hernia 
complicating  hydrocele  in  infants  so  frequently  that  they  recommend 
early  radical  cure  of  both  conditions. 

In  adults  chronic  hydrocele  shows  no  tendency  to  spontaneous 
recovery.  It  never  endangers  the  patient's  life  except  under  the  rarest 
complications  of  hemorrhage  and  infection.  The  percentage  of  cures 
under  the  various  methods  of  treatment  is  discussed  under  that  heading. 

Complications. — Two  or  more  forms  of  hydrocele  may  coexist,  and 
hernia  frequently  accompanies  hydrocele  in  children.  Suppuration 
is  uncommon  in  chronic  hydrocele.  Rupture  of  the  hydrocele  sac  is 
usually  regarded  as  rare,  but  Hastings13  believes  it  a  more  frequent 
accident  than  is  commonly  supposed.  It  may  occur  as  the  result  of 
trauma  or  muscular  action,  rarely  spontaneously.  The  tunica  vaginalis 
in  such  cases  is  nearly  always  the  seat  of  pathological  changes,  usually 
with  fibrous  thickening,  and  areas  of  fatty  degeneration.  A  ruptured 


468  HYDROCELE,   HEMATOCELE  AXD   VARICOCELE 

hydrocele  must  be  differentiated  from  elephantiasis  of  the  scrotum, 
from  extravasation  of  urine,  and  from  strangulated  hernia.  Heinato- 
cele  may  be  the  result  of  the  rupture  of  the  sac.  Rupture  only  rarely 
results  in  a  cure,  usually  the  hydrocele  refills,  unless  the  cavity  of  the 
sac  is  filled  with  blood  clots. 

Treatment. —  Historical. — There  is  scarcely  a  disease  for  the  cure  of 
which  physicians  for  centuries  have  devised  more  numerous  or  more 
ingenious  methods  of  treatment,  than  for  hydrocele.  Until  anatomists 
of  the  time  of  Monro,  Hunter  and  Pott  discovered  the  true  nature  of 
hydrocele,  there  was  "  supposed  to  be  an  immediate  connection  between 
the  coats  of  the  testicle,  liver,  kidneys,  and  other  viscera,  and  the  col- 
lection of  water  in  hydrocele  was  considered  a  deposition  from  these 
parts,  tending  to  free  them  and  perhaps  the  system  at  large  from  diseases 
of  importance."  Various  kinds  of  internal  medication  were  accordingly 
used,  with  local  applications  in  the  form  of  counter-irritants.  Simple 
tapping  of  the  hydrocele  was  a  very  early  measure.  Electricity  and 
electropuncture  were  employed,  on  the  principle  that  the  current  acted 
as  a  counter-irritant  and  also  possessed  some  coagulating  power  on 
albuminous  fluids.  The  injection  of  irritant  fluids  into  the  sac  following 
aspiration  was  among  the  earliest  methods  of  treatment,  and  is  still 
used  today.  Among  the  fluids  which  have  been  used  are  wine,  various 
acids,  iodine,  chlorine,  zinc  chloride,  alcohol,  ether,  chloroform,  adrena- 
lin, bichloride  of  mercury,  ferric  chlorate,  chloral  hydrate,  ergotin,  and 
silver  nitrate.  The  introduction  of  foreign  bodies  into  the  sac  after 
aspiration  has  also  been  extensively  practised  with  the  idea  that  the 
injection  of  an  irritant  fluid  had  too  transitory  an  effect  to  produce 
complete  obliteration  of  the  sac.  Some  of  the  substances  used  have 
been  rubber  tubes,  silk,  catgut,30  and  metal  strips.17 

Vaccine  therapy  has  been  used  in  hydrocele.  Mallanah16  reports  cures 
of  six  cases  in  which  an  injection  of  from  five  to  ten  mill  on  of  either  B. 
pyocyaneus  or  Staphylococcus  aureus  vaccine  was  made  into  the 
hydrocele  sac  after  aspiration  of  the  fluid.  Severe  reaction  occurred, 
followed  by  increase  in  size  of  the  hydrocele,  later  regression  to  a 
cure. 

Autoserotherapy  in  the  treatment  of  hydrocele  consists  in  total  or 
partial  aspiration  of  the  sac,  followed  by  subcutaneous  or  intramuscular 
injection  of  the  patient  with  his  own  fluid.  This  has  been  extensively 
practised  in  recent  years  by  foreign  investigators,  but  there  is  little 
American  literature  on  the  subject.  This  method  is  analogous  to 
similar  work  which  has  been  done  in  tuberculous  exudates  of  the  pleura 
and  peritoneum.  The  amount  of  fluid  injected  varies  with  different 
workers  from  1  to  20  c.c.  with  an  average  dose  of  5  c.c.  The  size  of  the 
dose  is  reported  to  make  little  difference  in  the  amount  of  local  reaction 
or  the  effect  on  the  hydrocele.  Injections  are  made  either  in  the  thigh, 
buttock,  or  abdomen.  Most  authors  who  have  tried  this  procedure 
have  reported  a  rapid  absorption  of  the  fluid  in  the  hydrocele  following 
the  autoserotherapy.  The  absorption  takes  place  within  the  first 
twenty-four  hours  and  then  remains  stationary.  There  is  seldom  local 


HYDROCELE  469 

reaction  or  fever.  In  most  cases  relapses  occur,  sometimes  imme- 
diately but  not  later  than  two  months.  These  cases  require  several 
reinjections. 

In  7o  cases  Caforio6  reports  that  absorption  of  the  fluid  in  the  hydro- 
cele  took  place  in  96  per  cent.  Relapses  occurred  in  80  per  cent,  but  by 
continuing  the  injections  42  per  cent,  were  permanently  cured,  as 
shown  by  absence  of  relapses  over  periods  varying  from  several  months 
to  years.  The  injection  of  hydrocele  fluid  from  other  patients  (hetero- 
serotherapy)  produced  no  effect.  Investigators  are  not  agreed  as  to 
how  this  method  produces  the  results  claimed,  and  until  the  nature  of 
the  process  involved  in  the  cure  is  better  understood,  it  must  be  regarded 
as  only  in  the  experimental  stage. 

Radical  surgical  operations  on  hydrocele  have  been  done  for  centuries. 
Incision  and  drainage  of  the  sac  was  practised  as  early  as  the  time  of 
Celsus,  who  also  excised  a  portion  of  the  skin  at  the  same  time.  But  the 
tremendous  reaction  resulting  from  the  infection  of  the  wound  made 
surgery  the  resort  of  the  more  adventurous  until  the  days  of  cleaner 
methods. 

When  Lister  introduced  the  principles  of  antisepsis,  hydrocele  was 
one  of  the  first  diseases  on  which  their  value  was  demonstrated.  Volk- 
mann,  in  1876,  gave  his  name  to  an  operation  which  consisted  in  wide 
incision  of  the  sac,  swabbing  its  cavity  with  carbolic  acid  and  sewing  the 
cdues  of  the  sac  to  the  skin  with  catgut.  Permanent  drainage  was  thus 
secured  until  obliteration  of  the  sac  by  granulation  took  place.  Von 
Bergmann,  in  1885,  was  one  of  the  first  to  practise  excision  of  the  sac. 
Since  that  time  many  surgeons  have  devised  changes  in  thetechnicof  the 
handling  of  the  sac,  and  in  providing  a  new  bed  for  the  testis. 

Present  Methods  of  Treatment. — The  methods  of  treatment  which 
need  concern  us  seriously  today  are  two : 

1.  The  purely  palliative  procedure  of  tapping  or  aspiration,  and 

2.  The  radical  operations  which  seek  to  obliterate  or  remove,  wholly 
or  in  part,  the  membrane  wrhich  secretes  the  serous  fluid.     These  are  of 
two  types:  (a)  The  closed  operation  of  aspiration  and  injection,  and  (6) 
the  open  operations,  consisting  in  total  or  partial  excision,  or  eversion  of 
the  sac,  or  a  combination  of  the  two. 

SIMPLE  TAPPING. — Indications. — Aspiration  of  the  fluid  of  a  hydro- 
cele does  not  contemplate  a  cure  but  merely  the  relief  of  symptoms.  It 
is  employed  when  the  patient  W7ill  not  consent  to  a  more  radical  pro- 
cedure or  when  some  constitutional  condition  centra-indicates  any 
operation.  It  may  be  used  to  advantage  in  children  when  the  hydro- 
cele is  uncomplicated,  and  at  times  results  in  a  cure. 

Technic. — After  proper  preparation  of  the  skin  and  after  locating  the 
position  of  the  testis  the  hydrocele  is  made  tense  by  grasping  it  from 
behind  between  the  palm  and  fingers  of  one  hand.  A  spot  free  from 
large  bloodvessels  on  the  lowrer  tense  anterior  surface  of  the  hydrocele  is 
selected  and  a  sharp  medium-sized  trocar  plunged  smartly  and  quickly 
into  the  sac,  using  one  finger  firmly  fixed  on  the  trocar  about  one-half 
inch  from  its  point  as  a  guard  against  too  deep  penetration.  With  a 


470  HYDROCELE,   IIEMATOCELE   AXD   VARICOCELE 

sharp  instrument  the  pain  of  puncture  is  slight  and  only  momentary, 
and  often  no  local  anesthetic  is  needed. 

On  withdrawing  the  needle  from  the  trocar,  if  the  fluid  does  not  run 
through  the  cannula,  it  generally  means  that  the  point  of  the  trocar  has 
pierced  only  the  skin  and  not  the  tunica  vaginalis,  so  that  farther  in- 
sertion is  necessary.  Care  must  be  taken  not  to  let  the  cannula  slip 
out  of  the  cavity  of  the  tunica  vaginalis  into  the  space  between  it  and 
the  skin  during  the  withdrawal  of  the  fluid,  as  this  results  in  infiltration 
of  the  scrotum.  A  collodion  dressing  of  the  puncture  wound  and  a 
suspensory  complete  the  aspiration.  . 

In  old  men  with  large  hydroceles  a  partial  removal  of  the  fluid  is  wise, 
followed  later  by  withdrawal  of  the  remainder.  Congestion  and 
hemorrhage  have  been  reported  following  too  great  changes  in  local 
conditions  after  the  complete  aspiration  of  a  large  sac. 

After  tapping,  the  hydrocele  usually  refills  in  from  two  to  six  months. 
Many  patients  are  content  with  a  semi-annual  relief  of  their  burden 
over  a  period  of  many  years. 

Complications. — The  trocar  may  wound  the  testis  when  it  has  been 
pulled  out  of  its  usual  posterior  position  by  adhesions.  This  rarely 
produces  any  serious  trouble.  Hemorrhage  from  the  sac  wall  due  to 
puncture  of  a  vessel  of  some  size  by  the  trocar  may  produce  hematocele. 
Both  of  these  accidents  may  be  avoided  by  transillumination  of  the  sac 
in  selecting  a  point  of  puncture.  The  course  of  bloodvessels  and  the 
position  of  the  testis  are  thus  made  clear. 

ASPIRATION  AND  INJECTION. — This  ancient  method  of  treatment  is 
still  in  considerable  use  today.  It  seeks  to  produce  obliteration  of  the 
cavity  of  the  tunica  vaginalis  by  the  injection  into  it  of  an  irritant 
following  the  aspiration  of  the  fluid.  The  drug  which  has  proved  the 
least  painful  and  the  most  sure  in  its  results  as  an  injection  is  carbolic 
acid. 

Indications. — This  procedure  is  indicated  in  a  restricted  class  of  cases, 
namely,  in  simple  uncomplicated  hydroceles  when  the  fluid  is  clear  and 
the  sac  wall  unchanged.  It  is  not  adapted  for  congenital  hydroceles,  for 
symptomatic  hydroceles  with  accompanying  disease  of  the  testis  or 
epididymis,  for  hydroceles  in  which  the  sac  wall  is  indurated,  infected,  or 
calcareous,  for  multilocular  hydroceles,  nor  for  hydroceles  complicated 
writh  hernia. 

Technic. — A  hypodermic  needle  detached  from  its  syringe  is  inserted 
into  the  upper  portion  of  the  hydrocele  sac,  and  after  the  escape  of  fluid 
through  the  needle  shows  that  it  is  in  the  sac  it  is  left  in  position  while 
the  hydrocele  is  completely  aspirated  to  the  last  possible  drop  by  a 
trocar  introduced  into  its  lower  anterior  portion.  The  trocar  is  then 
withdrawn  and  a  hypodermic  syringe  containing  from  5  to  20  minims  of 
pure  carbolic  acid  crystals,  deliquesced  by  heat,  is  attached  to  its  pre- 
viously inserted  needle.  The  acid  is  then  injected  into  the  sac  and  the 
scrotum  thoroughly  kneaded  in  order  to  spread  the  acid  through  the 
sac  cavity.  Care  should  be  taken  not  to  burn  the  scrotum  by  spilling 
any  of  the  acid;  alcohol  will  neutralize  the  effect  of  any  that  might 


HYDROCELE  471 

escape.  Both  puncture  wounds  are  sealed  with  collodion,  and  a  snug 
suspensory  applied. 

Some  authors  advise  washing  out  the  sac  after  aspiration  with  sterile 
salt  solution  until  the  wash  water  returns  clear,  in  order  to  remove  as 
much  albuminous  material  from  the  sac  \vall  as  possible  and  to  prevent 
it  from  neutralizing  the  effect  of  the  acid.  Keyes15  has  failed  to  note 
any  advantage  in  this  method. 

Pain  is  inconsiderable  owing  to  the  anesthetic  effect  of  the  carbolic 
acid.  Confinement  to  bed  is  not  necessary  after  the  injection,  though 
usually  patients  remain  quiet  one  or  two  days. 

After  the  injection  the  sac  partially  refills  with  inflammatory  exudate 
over  a  period  of  a  week  or  ten  days,  after  which  it  usually  begins  to 
recede.  If  still  large  and  tense  at  the  end  of  that  time  the  sac  should 
be  emptied  again  by  aspiration  without  a  second  injection.  If  it  then 
refills  for  a  second  time  the  case  is  not  suitable  for  injection  and  open 
operation  is  indicated. 

Keyes  believes  that  failures  of  the  injection  method  are  due  to  three 
causes:  (1)  improper  selection  of  cases;  (2)  errors  of  technic,  as  incom- 
plete evacuation  (the  most  frequent  cause  of  failure)  and  failure  to 
aspirate  a  second  time,  which  is  sometimes  part  of  the  cure ;  (3)  the  use 
of  iodine  instead  of  carbolic  acid,  the  former  being  more  painful  and  less 
certain  in  its  results. 

OPEN  OPERATIONS. — Indications. — One  of  the  many  variations  of 
open  operation  may  be  performed  in  any  type  of  hydrocele  except  in 
those  cases  in  which  the  patient's  preference  or  condition  allows  of 
palliative  treatment  only.  Open  operation  is  especially  indicated, 
moreover,  in  those  forms  of  hydrocele  mentioned  above  in  which  the 
injection  treatment  is  contra-indicated  or  likely  to  fail.  It  gives  the 
operator  the  additional  advantage  of  examining  the  testis  and  epi- 
didymis  for  the  presence  of  pathological  changes,  with  the  opportunity 
for  appropriate  treatment. 

Technic. — Local  or  general  anesthesia  may  be  used.  After  proper 
preparation  of  the  parts  a  high  incision,  three  or  four  inches  in  length, 
according  to  the  size  of  the  hydrocele,  is  made,  beginning  over  the 
external  abdominal  ring  and  extending  downward  along  the  course  of 
the  cord.  The  tunica  vaginalis  is  exposed  and  the  subsequent  steps 
differ  according  to  the  type  of  operation  to  be  done. 

SIMPLE  EVERSION  (Andrews' s  "Bottle"  Operation). — The  tunica 
vaginalis  is  opened  at  its  upper  pole  and  the  fluid  evacuated.  The  testis 
is  brought  outside  the  scrotum  and  extruded  through  the  opening  in  the 
sac,  which  is  made  only  large  enough  to  admit  of  the  passage  of  the 
testis  through  it.  The  sac  is  then  turned  inside  out  and  left  without 
suture,  or  one  or  more  sutures  may  be  passed  through  the  cut  edges  of 
the  sac,  securing  it  behind  the  cord  to  prevent  reinversion.  The  testis 
and  everted  sac  are  now  returned  to  the  scrotum  and  the  wound  closed 
without  drainage.  In  this  operation  the  convalescence  is  short  and 
there  is  little  danger  of  hemorrhage,  owing  to  the  absence  of  much 
dissection.  There  is  seldom  any  testicular  pain  and  the  averted  sac 


472 


HYDROCELE,   HEMATOCELE  AND  VAR1COCELE 


soon  shrinks.  The  disadvantages  of  the  operation  are  that  it  is  not 
successful  in  old,  thickened  hydroceles,  and  that  recurrence  is  not 
uncommon. 

K.KCISION  AND  E VERSION  (Winkelmamis  Operation]  is  the  procedure 
accepted  today  as  the  best  type.  After  dissecting  free  the  parietal  layer 
of  the  tunica  the  sac  is  trimmed  off  down  to  within  one-half  inch  of  its 
visceral  insertion  and  the  two  cut  edges  of  the  parietal  stump  are  sewed 
behind  the  testis  by  a  continuous  catgut  suture.  Great  care  must  be 
taken  to  secure  firmly  all  bleeding-points  in  the  cut  edges  of  the  stump  of 
the  sac  to  prevent  subsequent  hemorrhage.  The  wound  is  closed  with 
or  without  drainage,  as  may  seem  best  in  the  individual  case,  and  a  snug 
support  is  applied  over  the  dressing. 


FIG.  211. — Hydrocele. 


The  operator's  hand  rests  on  the  unopened  sac,  which  has  been 
dissected  free  down  to  the  cord. 


Bartlett1  has  described  a  method  of  total  extirpation  of  the  unopened 
hydrocele.  It  involves  a  rather  unnecessarily  tedious  dissection,  and  is 
suited  only  to  a  restricted  class  of  cases.  Vautrin28  believes  that  in 
long-standing  hydroceles  with  thickened  walls,  excision  with  eversion  is 
not  enough  to  prevent  recurrence,  and  he  makes  a  new  bed  for  the  testis 
in  the  connective  tissue  of  the  scrotum.  This  he  finds  an  absolute  safe- 
guard against  relapse.  Volkmann's  operation  of  wide  incision  of  the 
sac,  followed  by  swabbing  its  cavity  with  carbolic  acid  and  allowing  it  to 
become  obliterated  by  granulation,  has  been  abandoned  on  account  of 
the  slow  convalescence  and  the  likelihood  of  recurrence  due  to  local- 
ized fa  lure  of  obliteration.  Von  Bergmann's  operation  of  simple 
excision  of  the  sac  has  also  been  generally  replaced  by  one  of  the 
methods  given  above. 

Operative  Complications. — Operat'ons  for  hydrocele  may  be  followed 
by  hemorrhage,  atrophy  of  the  testis,  and  recurrence  of  the  disease. 


HYDROCELE  473 

Hemorrhage  may  take  place  as  a  result  of  the  tearing  of  vessels  during 
the  separation  of  the  sac  wall  or  from  the  stump  of  the  sac,  and  may 
develop  some  hours  after  operation,  at  which  hemostasis  was  appar- 
ently complete.  This  can  be  guarded  against  at  the  time  of  operation 
by  nice  attention  to  separation  of  the  sac  along  the  proper  line  of  cleav- 
age, where  one  meets  little  bleeding,  and  by  scrupulous  care  in  tying  off 
all  bleeding-points.  During  the  first  twenty-four  hours  following  oper- 
ation all  cases  should  be  frequently  inspected  for  evidence  of  bleeding. 
If  hemorrhage  occurs  there  is  early  complaint  on  the  part  of  the  patient 
of  pain  and  a  sensat'on  of  tension  in  the  scrotum.  When  the  loss  of 
blood  is  slight  it  may  be  left  to  be  absorbed ;  when  large  the  treatment 
becomes  that  of  hematocele. 


FIG.  212. — Hydrocele.  The  sac  has  been  excised  to  within  one-half  inch  of  the 
testis.  The  last  stitch  is  being  taken  in  the  everted  edges,  which  are  being  sewed  behind 
the  cord. 

Atrophy  of  the  Testis. — Certain  authors  believe  that  the  presence  of 
the  parietal  layer  of  the  tunica  is  necessary  to  integrity  of  the  testis  and 
that  its  removal  in  a  radical  cure  for  hydrocele  interferes  with  testicular 
function.  Others  claim  that  the  apparent  atrophy  of  the  testis  which 
has  been  reported  after  operations  on  hydroceles  is  due  either  to  a  press- 
ure atrophy  from  the  long-continued  presence  of  the  hydroce  e  or  to 
some  unusual  operative  complication  which  has  damaged  the  testis. 
Rolando4  extirpated  the  tunica  in  dogs  and  later  removed  the  testis  at 
varying  intervals  following  the  primary  operation.  He  reported  that 
the  testes  removed  early  were  smaller  and  softer  than  normal  and 
showed  thickening  of  the  albuginea  with  no  evidence  of  spermatogenesis, 
Those  removed  two  or  three  months  later  showed  spermatogenesis,  but 
not  in  normal  amount.  At  all  events  this  complication  is  rare  and  cannot 
be  considered  a  contra-indication  to  a  radical  cure  of  hydrocele. 


474  HYDROCELE,   HEMATOCELE  AXD   VARICOCELE 

Recurrence. — The  liability  to  recurrence  after  radical  operation  will 
be  considered  under  the  heading  of  Results. 

Results  of  Various  Types  of  Operation. — Brims4  has  collected  statistics 
from  a  large  number  of  operators,  from  which  may  be  compared  the 
merits  of  the  two  types  of  radical  operation  and  the  chances  of  subse- 
quent recurrence. 

A  f>- pi  ration  and  Injection. — From  reports  of  operators  using  either 
iodine  or  carbolic  acid  as  an  injection  fluid  he  found  1593  cases  with  95 
known  relapses,  or  6.1  per  cent.  Of  these  cases  a  certain  number  had 
been  followed  up  for  a  period  varying  from  a  few  months  to  some  years. 
There  were  505  cases  with  57  relapses,  or  11  per  cent.,  undoubtedly 
proving  that  the  percentage  of  relapse  for  the  entire  series  was  too  low. 
Of  these  505  cases  which  had  been  later  investigated,  iodine  had 
been  used  in  420  cases  with  45  relapses,  or  10.7  per  cent;  carbolic 
acid  had  been  used  in  85  cases  with  12  relapses,  or  14  per  cent. 
Reports  showed  that  carbolic  acid  was  less  painful  and  caused  less  local 
reaction,  consequently  a  shorter  convalescence.  There  wrere  no  reports 
of  intoxication  from  carbolic  acid,  as  has  been  the  case  with  the  use  of 
iodin. 

Open  Operations. — Of  all  types  of  open  operations  results  were  se- 
cured from  1216  cases  with  30  relapses,  or  2.4  per  cent.  Of  these  there 
had  been  late  investigation  of  412  cases  with  22  relapses,  or  5.33  per 
cent.  Thus  the  injection  method  for  the  whole  series  shows  two  and  a 
half  times  the  percentage  of  relapse  that  the  whole  series  of  open  opera- 
tions offers  (6.1  per  cent,  as  against  2.4  per  cent.). 

Choice  of  Method  of  Treatment. —  Tapping  has  its  place  as  a  purely 
palliative  measure  in  cases  in  which  the  patient's  desire  or  condition 
makes  it  necessary,  and  it  occasionally  may  result  in  a  cure  in  children. 

Aspiration  and  injection  may  be  expected  to  produce  a  definite 
number  of  cures  in  a  selected  class  of  cases.  It  possesses  the  advantage 
of  ambulatory  treatment,  short  convalescence,  and  the  avoidance  of 
whatever  slight  danger  attends  any  cutting  operation.  It  is  followed, 
however,  by  a  much  greater  percentage  of  failures  than  the  open 
operations. 

Open  operations  involve  hospital  confinement  and  a  longer  con- 
valescence. They  are  adapted,  however,  to  all  types  of  hydrocele  and 
are  followed  by  fewer  recurrences.  Since  it  is  not  alone  the  simplicity 
of  the  method  to  be  chosen  but  the  sureness  of  result  that  should  guide 
the  surgeon  in  his  advice  to  patients,  the  open  operation  remains  the 
most  rational  proceeding  in  that  it  gives  the  best  guarantee  of  cure. 

Hydroceles  due  to  Abnormalities  of  Development. 

These  forms  of  hydrocele  are  produced  by  interference  with  the  oblit- 
eration of  the  peritoneal  process  in  which  the  testis  descelids  through  the 
inguinal  canal,  and  require  separate  mention.  The  particular  type  of 
abnormality  associated  with  each  of  these  forms  has  already  been 
described  under  Varieties  of  Hvdrocele. 


HYDROCELE  475 

Congenital  Hydrocele. — This  form  of  hydrocele  occurs  in  infancy 
and  is  generally  idiopathic.  Rare  symptomatic  cases  have  been  re- 
ported with  congenital  lues  and  accompanying  orchitis.  The  idio- 
pathic type  is  due  to  muscular  straining  in  crying  or  too  tight  binders, 
causing  pressure  on  the  unclosed  processus  funicularis.  Peiser23  reports 
73  cases,  of  which  26  were  double,  33  on  the  right  side  and  14  on  the  left. 
In  the  prone  position  the  fluid  can  usually  be  pressed  back  into  the 
abdomen. 

Diagnosis. — Congenital  hydrocele  and  hernia  frequently  coexist. 
Both  extend  through  the  inguinal  canal  and  both  give  an  impulse  on 
coughing.  When  either  condition  exists  alone  they  may  be  differentiated 
by  the  fact  that  hernia  is  resonant  on  percussion  and  gives  a  gurgling, 
jerky  reduction;  it  is  not  translucent  and  the  testis  can  be  identified. 
Hydrocele  is  dull  to  percussion,  gives  an  even,  slow  reduction,  is  trans- 
lucent, and  until  after  reduction  the  testis  is  lost  in  the  hydrocele.  When 
both  conditions  are  present,  the  signs  may  be  confusing. 

Prognosis. — Many  cases  are  cured  spontaneously  during  the  first  year. 
Complication  with  hernia  somewhat  decreases  the  probability  of 
spontaneous  cure. 

Treatment. — Since  hernia  is  a  frequent  complication  some  authors9 
prefer  radical  treatment  between  the  third  and  sixth  months  to  expec- 
tant treatment.  If  present  the  hernial  sac  may  be  treated  at  the  same 
time.  Injection  treatment  should  never  be  used  in  this  type. 

Infantile  Hydrocele. — This  is  more  common  than  the  congenital 
form;  because  the  fluid  does  not  communicate  with  the  abdominal 
cavity  the  hydrocele  is  always  irreducible.  Hernia  is  a  frequent  com- 
plication. "Hydrocele  en  bissac"  is  a  rare  type  of  infantile  hydrocele 
in  which  a  portion  of  the  hydrocele  is  in  the  scrotum  and  a  portion  in  the 
abdomen. 

Treatment.  —  Open  operation,  never  injection,  on  account  of  the 
possibility  of  hernia  coexisting. 

Inguinal  Hydrocele. — This  is  a  rare  form  of  hydrocele  surrounding 
an  undescended  testis.  The  treatment  of  the  testis  governs  the  treat- 
ment of  the  hydrocele. 

Hydrocele  of  the  Cord. — Hydroceles  of  the  cord  are  of  two  varieties, 
diffuse  and  encysted. 

Diffuse  Type. — The  true  diffuse  form  is  a  boggy  infiltration  of  the 
connective  tissue  about  the  cord  following  the  rupture  of  a  hydrocele  or 
spermatocele.  Under  the  name  of  multilocular  hydrocele  of  the  cord  are 
grouped  echinococcus  cysts,  cysts  of  fetal  remains  and  other  rare  types. 

Symptoms. — The  diffuse  and  multilocular  types  present  a  boggy 
tumor  of  irregular  outline,  which  may  extend  from  the  scrotum  to  the 
inguinal  canal  or  higher.  The  mass  may  be  somewhat  translucent,  with 
slight  impulse  on  coughing,  and  partial  reducibility. 

Diagnosis. — The  tumor  is  to  be  diagnosed  by  its  translucency  and 
general  irregular,  boggy  feel.  In  other  respects  it  suggests  an  incar- 
cerated omental  hernia,  and  may  occasionally  be  identified  only  after 
incision. 


476  HYDROCELE,  HEMATOCELE  AND   VARICOCELE 

Treatment. — Often  no  treatment  is  advisable;  incision  has  been  used. 

Encysted  Hydrocele  of  the  Cord. — This  form  represents  a  localized  col- 
lection of  fluid  in  the  course  of  the  cord.  The  fluid  does  not  communi- 
cate with  the  tunica  vaginalis  below  nor  the  peritoneum  above.  Cysts 
may  be  large  or  small,  single  or  multiple.  They  occur  more  often  in 
children  than  adults. 

Treatment. —  Tapping  alone  in  children  is  often  curative.  Aspiration 
and  injection  with  carbolic  acid  is  useful  in  cases  where  the  cyst  is  below 
the  external  ring.  For  cysts  in  the  inguinal  canal  excison  is  indicated 
on  account  of  the  danger  of  hernia  as  a  complication.  Hematocele  may 
follow  injury  to  one  of  these  hydroceles  of  the  cord  and  demands  the 
usual  treatment  of  hematocele  of  the  tunica  vaginalis. 

Hydrocele  of  a  Hernial  Sac. — A  collection  of  fluid  in  the  sac  of  a 
hernia  after  its  contents  have  been  reduced  and  after  either  spontane- 
ous or  artificial  obliteration  of  the  neck  of  the  sac.  It  must  be  differen- 
tiated from  a  recurrent  hernia. 

Treatment. — Excision. 

HEMATOCELE. 

An  hematocele  is  formed  when  there  is  hemorrhage  into  the  cavity  of 
any  form  of  hydrocele.  Hemorrhage  into  the  tissues  is  properly 
termed  hematoma.  As  infiltrations  of  the  scrotum  and  testis  with 
blood  often  accompany  the  bleeding  into  the  hydrocele  sac,  we  fre- 
quently have  the  combination  of  hematocele  and  hematoma,  to  both  of 
which,  however,  the  former  term  is  generally  applied. 

Etiology. — Hematocele  may  be  traumatic  or  spontaneous  in  origin. 
If  traumatic  (1)  it  follows  blows  or  crushing  injuries  of  the  scrotum  and 
its  contents,  in  which  case  the  hemorrhage  may  infiltrate  the  scrotum 
as  well  as  the  hydrocele  sac,  or  (2)  it  may  be  the  result  of  hemorrhage 
subsequent  to  any  operation  upon  a  hydrocele  or  upon  the  epididymis 
or  testis.  Spontaneous  hemorrhage  into  a  hydrocele  sac  may  occur  in 
conditions  of  arteriosclerosis  and  scorbutus. 

Symptoms. —  Traumatic  hematocele  develops  quickly  with  pain  and 
tension  in  the  scrotum  and  rapid  increase  of  size  of  the  hydrocele  sac. 
Skin  ecchymoses  are  frequently  present.  Spontaneous  hematocele  is  of 
slow  and  insidious  development,  is  almost  never  painful,  and  resembles 
the  growth  of  a  hydrocele.  The  contents  of  a  recent  hematocele  are 
fresh  blood,  which  later  becomes  brownish  or  chocolate-colored  from 
admixture  with  fibrin  and  disintegration.  The  sac  cavity  may  be 
entirely  obliterated  by  fibrinous  growths  projecting  from  the  sac  wall 
and  pressure  on  the  testis  in  long-standing  cases  may  cause  its  complete 
atrophy.  Barrington1  reports  a  case  of  spontaneous  rupture  in  a 
hematocele  of  nine  years'  duration.  Examination  of  the  testis  removed 
at  operation -showed  that  though  it  appeared  normal  macroscopically, 
there  was  entire  degeneration  of  the  tubules. 

Diagnosis. — ^Yith  a  definite  history  of  recent  injury  to  or  operation 
on  the  scrotal  contents,  the  diagnosis  of  hematocele  is  easy  and  is  made 


SPERMATOCELE  477 

by  the  same  signs  as  those  presented  by  acute  hydrocele  minus  the 
translucency  and  with  the  usual  added  presence  of  ecchymoses.  The 
real  difficulty  in  diagnosis  is  to  differentiate  the  slowly  developing  pain- 
less hematocele  caused  by  spontaneous  hemorrhage  into  the  tunica 
vaginalis  from  a  neoplasm  of  the  testis.  Woolfenden3  reports  a  sup- 
posed case  of  hematocele,  which  was  assigned  to  students  by  examiners 
for  the  degree  of  M.B.,  which  at  later  operation  proved  to  be  a  sarcoma 
of  the  testis. 

Treatment. — Ordinary  traumatic  hematocele  requires  the  same  treat- 
ment as  acute  hydrocele — rest,  elevation,  and  hot,  moist  dressings. 
Many  authors  recommend  the  application  of  ice  and  cooling  lotions,  but 
they  are  not  as  grateful  to  patients,  in  our  experience  at  least,  as  some 
form  of  heat.  Extensive  hemorrhage  with  danger  of  atrophy  of  the 
testis  from  pressure  or  suppuration  demands  incision  and  drainage. 
With  the  more  slowly  developing  type  of  hematocele  due  to  spontaneous 
hemorrhage,  unless  the  history  is  perfectly  clear,  it  is  far  safer  to  operate 
to  prove  or  exclude  the  presence  of  a  malignant  growth  of  the  testis. 
Orchidectomy  is  indicated  in  long-standing  hematocele. 


CHYLOCELE  (GALACTOCELE). 

This  is  a  rare  condition  in  which  chyle  is  present  in  the  tunica 
vaginalis.  It  is  usually  seen  in  the  tropics  and  is  due  to  the  presence 
of  the  Filaria  sanguinis  hominis  in  the  lymphatics  of  the  cord,  causing 
engorgement  and  leakage  of  the  chyle  into  the  tunica  vaginalis.  It 
resembles  hydrocele  except  that  its  contents  are  milky  and  the  patient 
presents  the  symptoms  of  filariasis. 

Treatment. — The  treatment  consists  in  excision,  with  an  attempt  to 
remove  the  affected  lymphatics. 


SPERMATOCELE. 

Etiology. — Spermatoceles  are  true  retention  cysts  in  or  about  the 
epididymis  or  rarely  of  the  testis  and  are  produced  by  any  process 
which  blocks  the  outlet  of  seminiferous  tubules,  leading  to  distention 
of  the  tubule  by  semen,  which  continues  to  be  secreted,  and  cyst  forma- 
tion. The  present  view  discredits  the  theory  of  the  origin  of  sperma- 
tocele  in  fetal  remains. 

With  relation  to  the  tunica  vaginalis  these  cysts  may  be  extravaginal 
or  intravaginal.  The  extravaginal  type  is  the  more  common  and  usually 
arises  behind  the  testis  and  between  it  and  the  epididymis,  and  develops 
in  a  direction  in  which  there  is  no  covering  of  tunica  vaginalis.  The 
intravaginal  type  develops  from  some  portion  of  the  epididymis,  which 
is  covered  with  tunica  vaginalis,  and  pushes  it  ahead  of  it  in  its  growth. 
These  cysts  may  attain  large  size  and  entirely  fill  the  cavity  of  the  tunica 
vaginalis.  Their  rupture  into  the  cavity  is  held  to  be  a  cause  of  hydro- 


47S  HYDROCELE.   HEMATOCELE  AXD   VARICOCELE 

cele  as  well  as  to  account  for  the  presence  of  spermatozoa  found  in  some 
hydroceles.  Spermatocele  occurs  mostly  between  the  ages  of  twenty 
and  forty:  there  are  few  cases  in  old  men.  It  is  more  frequent  on  the 
right  than  on  the  left  side  and  may  be  bilateral;  it  may  accompany 
hydrocele. 

Pathology. — Spermatoceles  conform  to  the  type  of  true  retention  cysts 
in  that  they  arise  from  a  preformed  cavity,  they  are  lined  with  its 
epithelium,  and  their  contents  correspond  to  that  of  the  affected  organ. 
Injection  preparations  have  been  made  from  spermatoceles  showing 
direct  connection  with  seminiferous  tubules.  The  larger  cysts  which 
usually  occur  in  young  adult  life  are  attributed  to  obstructive  processes 
in  the  vasa  efferentia,  and  the  smaller  cysts  of  later  life,  to  senile  cystic 
enlargement  of  the  tubules. 

Fluid. — The  fluid  of  spermatocele  is  milky  and  filled  with  seminal 
elements.  Its  amount  rarely  exceeds  three  or  four  ounces,  although 
have  been  reported  in  which  over  fifty  ounces  were  withdrawn. 
As  distinguished  from  hydrocele  fluid  it  is  cloudy,  neutral,  of  light 
specific  gravity  (1009),  and  contains  less  solids  and  albumin.  The 
spermatozoa  may  be  motile  or  dead.  The  former  occurs  if  a  connection 
exists  between  the  cyst  and  seminiferous  tubules,  through  which  fresh 
semen  is  constantly  supplied.  If  the  spermatozoa  are  dead  it  is  sup- 
posed that  the  connection  with  vasa  efferentia  has  been  lost. 

Symptoms. — The  cysts  of  young  adult  life  present  the  signs  of  a  slowly 
growing  painless  enlargement  at  the  top  of  the  testis.  Pain  at  the  end 
of  intercourse  has  been  reported  in  a  few  cases  of  the  intravaginal  type. 
The  tumor  is  usually  heart-shaped  and  may  grow  to  large  size,  produc- 
ing a  sense  of  dragging  on  the  cord.  It  is  not  translucent,  may  be 
fluctuant,  and  is  elastic  and  tense.  The  position  of  the  testis  depends 
upon  the  direction  of  growth  of  the  spermatocele,  and  may  be  pushed 
forward,  downward,  or  backward. 

Diagnosis. — The  demonstration  of  a  heart-shaped  tumor  above  and 
behind  the  testis  and  the  recovery  of  the  typical  fluid  by  aspiration 
are  the  chief  means  of  diagnosis.  The  shape  of  the  tumor,  however,  is 
not  constant  nor  its  position  with  relation  to  the  testis.  The  testis  and 
epididymis  can  be  more  clearly  palpated  than  in  hydrocele,  when  they 
are  surrounded  by  it.  If  the  spermatocele  is  complicated  by  hydrocele, 
or  if  it  is  of  the  intravaginal  type,  the  diagnosis  will  only  be  made  by 
aspiration.  Hydrocele  of  the  cord  cannot  at  times  be  differentiated 
from  spermatocele.  The  former  occurs  chiefly  in  childhood,  however,  is 
distinctly  separable  from  the  testis  and  epididymis  and  fixed  as  a  part  of 
the  vas. 

Treatment. — Small  cysts  require  no  treatment.  Aspiration  and  in- 
jection are  usually  ineffectual  and  not  to  be  advised.  Larger  cysts 
should  be  excised.  After  incising  the  skin  over  the  cyst  it  is  opened, 
its  contents  evacuated,  and  the  cyst  wall  shelled  out.  Often  a  well- 
defined  pedicle  is  found  which  should  be  tied  off.  The  wound  is  closed 
with  or  without  drainage  as  seems  best. 


VAKICOCELE 

VARICOCELE. 

Yaricocele  is  a  condition  in  which  there  is  dilatation,  elongation, 
and  tortuosity  of  the  veins  of  the  spermatic  cord.  It  is  generally 
limited  to  the  spermatic  vein,  although  occasionally  the  cremasteric 
and  deferential  veins  may  also  be  affected. 

Anatomy. — The  spermatic  vein  originates  at  the  posterior  border  of 
the  testis  as  a  thick  network  of  eight  to  ten  vessels  called  the  pampini- 
form  plexus,  most  of  which  lies  anterior  to  the  cord.  These  veins  pass 
upward  through  the  inguinal  canal  and  unite  into  one  trunk  in  the  ab- 
dominal cavity.  The  vein  of  the  right  side  passes  into  the  vena  cava, 
the  left  vein  into  the  left  renal  vein. 

Symptomatic  Varicocele. — Varicocde  may  be  symptomatic  or  idio- 
pathic.  The  symptomatic  type  is  the  result  of  obstruction  to  the  sper- 
matic vein  by  some  abdominal  tumor.  It  is  rare,  occurs  late  in  life, 
develops  rapidly,  and  is  associated  with  malignant  growths,  especially 
of  the  left  kidney,  though  it  may  be  produced  on  either  side.  White14 
reports  a  case  of  acute  left  varicocele  of  six  weeks'  duration  which 
immediately  disappeared  on  the  removal  of  a  pyonephrotic  left  kidney. 

Diagnosis. — The  age  of  occurrence,  its  rapid  and  painless  develop- 
ment, and  the  fact  that  when  the  patient  lies  down  the  veins  do  not 
empty  themselves  as  in  ordinary  varicocele  are  the  principal  points  of 
diagi; 

Treatment. — The  varicocele  disappears  with  the  removal  of  its  cause. 

Idiopathic  Varicocele. — Etiology. — This  type  is  a  common  condition 
in  young  men  between  the  ages  of  fifteen  and  thirty-five.  In  a  study  of 
40o  cases  Barney1  found  SI  per  cent,  occurred  between  those  ages,  and 
were  unmarried.  Youth  and  celibacy  seem  to  be  suggestive  factors. 
The  classical  location  is  the  left  side  (over  90  per  cent.),  the  right  side  is 
rarely  affected  alone, and  both  sides  more  rarely.  Of  391 1  cases,  Curling1 
found  3360  on  the  left,  282  on  the  right,  and  269  bilateral.  Sistach,1 
in  7011  cases,  found  308  on  the  right  and  305  bilateral. 

Many  causes  have  been  adduced  to  account  for  varicocele.  To  say 
that  the  spermatic  veins  are  long  and  tortuous,  with  a  vertical  course, 
and  receive  little  or  no  support  from  the  loose  surrounding  tissues, 
offers  a  seemingly  reasonable  explanation,  but  these  factors  are  present 
in  every  male,  and  all  men  do  not  have  varicocele.  To  account  for  the 
preponderance  of  left-sided  varicoceles  are  the  anatomical  facts ;  that  the 
left  testis  hangs  lower  than  the  right,  the  left  spermatic  vein  is  conse- 
quently longer;  it  has  no  valves,  and  empties  at  right  angles  into  the 
left  renal  vein,  where  it  is  less  advantageously  drained  than  on  the  right 
side,  where  the  vein  enters  the  vena  cava  at  an  acute  angle  and  a  lower 
level.  These  facts  are  undoubtedly  of  importance,  but  they  still  do  not 
explain  the  occurrence  of  varicocele  in  the  young  and  its  comparative 
absence  in  the  old,  in  whom  conditions  would  be  supposedly  ideal  for  its 
development.  The  most  probable  explanation  is  that  varicocele  is  a 
functional  disorder,  due  to  a  local  chronic  passive  congestion  induced 
by  unrelieved  sexual  stimulation  or  by  overindulgence.  This  hypothe- 


480  HYDROCELE,   HEMATOCELE  AXD   VARICOCELE 

sis  would  account  for  the  frequent  disappearance  of  varicocele  under  the 
normal  sex  relations  of  married  life  and  its  absence  in  old  men  whose 
sexual  powers  are  in  abeyance.  A  congenital  diathesis  to  varices,  con- 
stipation and  trauma,  claimed  as  contributing  factors,  probably  have 
no  relation  to  the  production  of  varicocele. 

Pathology. — The  veins  may  be  merely  tortuous  and  dilated,  or  the 
process  may  go  on  to  the  stage  of  complete  break-down  of  the  valves 
with  fatty  atrophy,  areas  of  thickening,  and  phlebolith  formation. 

Symptoms. — Yaricocele  may  produce  no  subjective  symptoms  even 
though  of  considerable  size.  Conversely  a  small  developing  varicocele 
may  be  the  cause  of  a  great  deal  of  dragging  pain  along  the  course  of  the 
cord  and  in  the  testis.  This  is  probably  analogous  to  the  pain  in  the 
leg  at  the  time  of  development  of  a  varix. 

Mcnt<tl  xi/ii/ptoms  varying  from  mild  sexual  neurasthenia  to  melan- 
cholia are  often  associated  with  this  as  with  other  genital  diseases. 
The  quack  and  the  charlatan  have  found  in  varicocele  a  gold  mine. 

The  objective  symptoms  are  the  low-hanging  testis,  the  relaxed 
scrotum,  and  the  mass  of  enlarged  tortuous  veins.  The  scrotal  veins 
may  at  times  be  affected  also.  When  the  patient  lies  down  the  veins 
empty  themselves  and  the  varicocele  disappears.  Atrophy  of  the  testis 
follows  a  long  interference  with  its  circulation,  but  is  comparatively 
uncommon  (11  per  cent.).1  Many  cases  of  restoration  of  the  testis  to 
normal  size  and  consistency  after  operation  have  been  reported,  and 
certain  authors  believe  that  the  apparent  atrophy  was  merely  under- 
development. 

Diagnosis. — The  peculiar  feel  of  the  enlarged  veins  in  varicocele  is  so 
characteristic  that  it  is  not  likely  to  be  confounded  with  any  condition 
except  an  omental  hernia.  This  may  be  differentiated  as  follows:  If 
after  the  veins  are  emptied  by  having  the  patient  lie  down  the  finger  is 
held  over  the  external  ring  and  the  patient  rises,  the  varicocele,  if  one  is 
present,  refills,  while  an  omental  hernia  is  held  back  by  the  finger.  The 
complicating  presence  of  a  hydrocele  or  hernia  may  make  the  diagnosis 
more  difficult. 

Treatment. — Many  varicoceles  require  no  treatment,  as  they  produce 
no  discomfort.  The  local  symptoms  produced  by  many  others  may  be 
entirely  relieved  by  the  use  of  a  snug  suspensory.  The  patient  should 
be  strongly  assured  that  his  disease  is  not  serious  and  that  it  will  not 
lead  to  impotency  or  any  other  of  the  dire  results  of  which  these  sufferers 
are  apprehensive.  Mental  symptoms  should  be  met  by  a  rational 
psychotherapy,  with  sex  hygiene  and  marriage  offered  as  a  solution  of 
the  trouble. 

Indications  for  Operation. — For  the  cases  in  which  for  various  causes 
the  foregoing  measures  do  not  suffice,  operative  treatment  is  indicated. 
In  Barney's1  series  of  403  cases  the  patients  came  to  operation  for  the 
following  reasons:  unrelieved  and  persistent  pain,  270;  no  special  rea- 
son given,  68;  inconvenience,  22 ;  mental  symptoms,  18;  qualifications 
for  civil,  army,  or  navy  service,  17;  recurrence  following  previous 
operations  elsewhere,  8, 


VARICOCELE 


In  the  German  army15  a  suspensory  is  first  tried  with  officers  and  men 
complaining  of  symptoms  from  their  varicoceles.  If  they  are  not  re- 
lieved by  this  treatment  operation  is  done. 


FIG.  213. — Varicocele.     The  veins  have  been  separated   from  the  cord,   and  ligated 

above  and  below. 


FIG.  214. — Varicocele.     A  section  of  the  veins  has  been  excised,  and  the  two  stumps 

are  being  tied  together. 
M  tr     i — 31 


482  HYDROCELE,  HEMATOCELE  AXD  VARICOCELE 

Operation  is  indicated  then  in  varicoceles  for  persistent  pain  unre- 
lieved by  a  suspensory;  for  uncomfortable  size;  in  cases  in  which 
atrophy  of  the  testis  is  feared;  and  in  the  presence  of  marked  neurotic 
symptoms.  The  operation  in  itself,  however,  will  not  cure  sexual  neu- 
roses, and  we  have  seen  patients  who  were  so  disappointed  at  lack  of 
immediate  results  that  their  last  state  was  worse  than  the  first.  A 
course  of  psychotherapy  following  the  operation  is  important  with 
neurotic  patients,  and  no  operation  should  ever  be  done  on  them  with- 
out the  existence  of  a  definite  pathological  condition  in  the  veins.  Other 
indications  for  operation  are  the  absence  or  disease  of  the  other  testis, 
the  complication  of  hernia  or  hydrocele  of  the  same  side,  a  history  of  a 
recurrent  phlebitis,  thrombosis,  spontaneous  rupture,  or  calcareous 
condition  of  the  veins. 

Types  of  Operation. — Varicocele  may  be  treated  by  subcutaneous 
li  (future  or  by  open  operation,  involving  excision  of  a  portion  of  the  veins 
with  elevation  and  support  of  the  testis. 

Subcutaneous  ligation  of  the  veins  of  a  varicocele  is  a  blind  and  un- 
surgical  procedure.  It  presents  the  danger  of  hemorrhage  from  the 
wounding  of  a  vein  with  a  needle  and  the  possibility  of  recurrence  from 
the  failure  of  the  ligature  to  obliterate  the  vein.  It  offers,  further,  no 
support  for  the  testis.  The  method  should  be  abandoned  in  view  of  the 
simplicity  and  efficiency  of  the  following  operation. 

Open  Operation. —  Technic. — Local  or  general  anesthesia  may  be  used, 
preferably  the  latter  if  the  patient  is  neurotic.  A. high  incision  two 
inches  long  is  made  above  the  inguinal  canal  with  its  lower  end  over  the 
external  ring.  The  dissection  is  carried  down  to  the  cord  with  its  over- 
lying veins  and  the  fascia  enclosing  it  opened.  At  this  level  the  veins 
have  united  into  three  or  four  trunks,  and  may  easily  be  separated  from 
the  vas  and  its  vessels.  By  pulling  up  the  testis  into  the  incision  the 
separation  may  be  carried  down  to  within  one  inch  of  it.  The  separated 
mass  of  veins  is  ligated  above  and  below  and  a  sufficient  section  is 
excised  so  that  by  approximating  the  two  stumps  the  testis  will  'be 
elevated  to  a  proper  position  opposite  its  mate.  Great  care  should  be 
taken  to  secure  firmly  all  the  cut  veins  by  individual  ligatures  if  neces- 
sary. The  distal  stump  of  veins  is  then  brought  up  to  the  proximal 
stump  and  tied  to  it,  which  serves  as  a  support  for  the  testis.  Fascia 
and  skin  are  closed  without  drainage  and  a  suspensory  dressing  applied. 
Patients  should  be  kept  in  bed  about  a  week. 

Ablation  of  the  scrotum  with  the  idea  of  providing  a  support  for  the 
testis  is  a  useless  procedure,  as  the  scrotal  skin  which  remains  is  capable 
of  further  stretching.  It  is  also  unnecessary  for  the  purpose  of  remov- 
ing redundant  tissue,  as  this  will  slowly  contract  when  the  weight  of  the 
testis  is  removed  by  elevation. 

Complications. — Atrophy  of  the  testis  and  traumatic  hydrocele  are 
rare  sequels  to  operative  treatment.  The  hydrocele  if  it  occurs  may 
be  left  to  absorb  or  may  require  tapping. 

Results. — In  the  series  quoted  above  a  certain  number  of  the  cases 
were  investigated  at  periods  of  from  one  to  ten  years  after  operation. 


VARICOCELE  483 

Of  these,  36  per  cent,  still  complained  of  some  pain  in  the  groin  or  testis; 
27  per  cent,  had  some  form  of  sexual  neurosis;  and  15  per  cent,  had 
recurrences.  On  the  other  hand,  there  was  no  case  of  atrophy  of  the 
testis;  in  30  per  cent,  the  testis  had  grown  larger  since  operation,  and 
80  per  cent,  acknowledged  they  had  been  distinctly  benefited. 

BIBLIOGRAPHY. 

HYDROCELE. 

1.  Bartlett:  Extirpation  of  the  Unopened  Hydrocele,  Jour.  Am.  Med.  Assn.,  1909, 
liii,  2149. 

2.  Bennett:  A  Case  of  Traumatic  Hydrocele  and  Injury  to  the  Perineum,   Clin. 
Jour.,  London,  1910,  xxxvii,  289. 

3.  Blakeway:  Encysted   Hydrocele   of   the   Epididymis,    St.    Bartholomew's   Hosp. 
Rep.,  1911,  xlvi,  192. 

4.  Bruns:  Die  Behandlung  der  Hydrocele  (Inaugural  Dissertation),  Berlin,  1912. 

5.  Caforio:  Sulla  patogenesi  dell'  idrocele  essenziale  contributo  alia  diagnosi  differen- 
ziale  fra  essudati  e  transudati,  Gazz.  internaz.  di  med.,  1912,  xv,  1089. 

6.  Caforio:  Ricerche  ulteriori  sull'autosieroterapia  dell'  idrocele,  e  sul  meccanismo 
di  azione  degli  autosieri,  Riforma  med.,  1912,  xxviii,  982  and  1014. 

7.  Cummins:  Hydrocele  en  Bissac,  Jour.  Roy.  Army  Med.  Corps,  1912,  xviii,  76. 

8.  D' Alberto:  Nuovo  processo  di  cura  radicale  dell'  idrocele,  Gazz.  d.  osp.,  Milano, 

1910,  xxxi,  561-562. 

9.  Dunn:  The  Association  of  a  Patent  Funicular  Process  with  Certain  Forms  of 
Hydrocele,  Brit.  Med.  Jour.,  1909,  ii,  758. 

10.  Fiori:  Dell'   autosieroterapia  in  generale  con  speciale  riguardo  ai  risultati  dell' 
autosieroterapia  dell'  idrocele,  Riv.  ospedal.,  Roma,  1912,  ii,  1-8;  also  Med.  ital.  Napoli, 

1912,  x,  1-8. 

11.  Formiggini:  Contributo  allo  studio  delle  cisti  del  funicolo  spermatico  di  origine 
connettivale,  Riforma  med.,  Napoli,  1913,  xxix,  1269  and  1300. 

12.  Fracassini:  Sopra   una   varieta   non   comune   d'idrocele,    Policlin.,    Roma,    1910, 
xvii,   1518-1521. 

13.  Hastings:  On  Rupture  of  the  Tunica  Vaginalis  in  Hydrocele,   Lancet,   1910,  i, 
916-919. 

14.  Lockwood:  Hydrocele  of  the  Cord,  Urol.  and  Cutan.  Rev.,  1914,  xviii,  534. 

15.  Keyes:  Diseases  of  the  Genito-urinary  Organs. 

16.  Mallanah:  A  Vaccine  Treatment  of  Hydrocele,  Brit.  Med.  Jour.,  1912,  i,  184. 

17.  Marcozzi:  Une  nouvelle  methode  de  traitement  de  1'hydrocele  avec  le  fil  de 
magnesium,  Ann.  des  mal.  des  organ.  Genit.  Urinaires,  1*909,  i,  739. 

18.  Morestin:  Hydrocele  rompue,  Bull,  et  mem.  Soc.  de  chir.,  1912,  xxxviii,  542-544. 

19.  Morestin:  Hydrocele  vaginale  traitee  par  la  ponction  formolee,  Bull,  et  mem.  Soc. 
de  chir.,  1912,  xxxviii,  1460;  ibid.,  1913,  xxxix,  791. 

20.  Moschcowitz:  Hydrocele  of  the  Tunica  Vaginalis;   Two   Recurrences  after  the 
Winrkelmann  Operation,  Ann.  Surg.,  1913,  Iviii,  561. 

21.  Miiller:  Ein  Beitrag  zur  operation  der  hydrokele,  Zentralb.  f.  Chir.,  1913,  xl,  1140. 

22.  Nicoll:  Six  Cases  of  Hydrocele  in  Infants  Treated  by  Operation,  Brit.  Med.  Jour., 

1913,  i,  384. 

23.  Peiser:  Ueber  Phimose  und  Hydrokele  in  Sauglingsalter,  Berlin,  klin.  Wchnschr., 
1912,  xlix,  1084-1086. 

24.  Posner:  Zur  Pathologie  und  Therapie  der  Hydrokele,   Berlin,   klin.  Wchnschr., 

1911,  xlviii,  390. 

25.  Ransohoff:  Venous    Thrombosis    and    Hydrocele    of    the    Inguinal    Canal,    Ann. 
Surg.,  1908,  xlviii,  247. 

26.  Squier:  An  Unusual  Type  of  Hydrocele,  Jour.  Am.  Med.  Assn.,  1913,  Ix,  1226. 

27.  Tait:  Recurrence  of  Hydrocele  after  Radical  Treatment,  California  State  Med. 
Jour.,    1913,    xi,   258. 

28.  Vautrin:  La  cure  operatoire  de  1'hydrocele  vaginale,  Arch.  gen.  de  chir.,  1913,  ix, 
897-913. 

29.  Vecchi:  Allo  studio  del  liquid  d'idrocele,   Gazz.   med.  ital.,   Torino,    1912,   Ixiii, 
211  and  221. 

30.  Whitney:  Hydrocele  and  its  Radical  Cure  by  the  Insertion  of  Catgut,  Boston 
Med.  and  Surg.  Jour.,  1911,  clxv,  204-211. 


484  HYDROCELE,  HEMATOCELE  AND  VARICOCELE 

31.  Wilkinson:  The  Radical  Operation  for  Hydrocele,  Am.  Jour.  Dermat.  and  Genito- 
urinary Dis.,  1911,  xv,  376. 

32.  Zaffiro:  Contribute  all  studio  dell'  idrocele  multiloculaire  e  delle  cisti  connettivale, 
Gior.  di  med.  mil.,  Roma,  1913,  Ixi,  108-119. 

33.  Zdanowicz:  Zur  Frage  iiber  die  Anwendung  der  Autoserotherapie  bei  Hydrokele, 
Ztschr.  f.  Urol.,  1913,  vii,  386. 

HEMATOCELE. 

1.  Barrington'  Spontaneous   Rupture   of  a  Hematocele  of   the   Tunica   Vaginalis, 
Brit.  Jour.  Surg.,  ii,  No.  7,  p.  398. 

2.  Harrison:  Hematocele    Studied    with   Reference   to   Etiology,   Pathogenesis,   and 
Therapeutics,  Virginia  Med.  Semimonthly,  1911-12,  xvi,  53. 

3.  Woolfenden:  On   the   Similarity   between  the  Signs  of   Hematocele  and   Early 
Malignant  Disease  of  the  Testis,  Med.  Press  and  Circ.,  1911,  xcii,  198. 

SPERMATOCELE. 

1.  Ebert:  Ueber  Spermatocele  (Inaugural  Dissertation),  Leipzig,  1912. 

2.  Hanusa:  Ueber  Spermatocele,  Beitr.  z.  klin.  Chir.,  1910,  Ixix,  255. 

3.  Posner:  Remarks  on  Spermatocele,  Am.  Jour.  Urol.,  1908,  iv,  237. 

4.  Whitney:  The  Etiology  and  Diagnosis  of  Spermatocele,  with  a  Report  of  Three 
Cases,  Am.  Jour.  Urol.,  1907,  iii,  175. 

VARICOCELE. 

1.  Barney:  Varicocele:  An  Analysis  of  Four  Hundred  and  Three  Cases,  Pub.  Mass. 
Gen.   Hosp.,    1910,   iii,   335. 

2.  Blech:  Varicocele:  its  Pathology  with  Reference  to  the  Soldier  and  a  New  Opera- 
tion for  its  Relief,  Mil.  Surg.,  1910,  xxvi,  5-39. 

3.  Corner:  Ligation  of  the  Spermatic  Artery  in  the  Operation  for  Varicocele,  Lancet, 
IQll.ii,  1094. 

4.  Frank:  Eine  neue  Methode  zur  Operation  der  Varikokele,  Zentralb.  f.  Chir.,  1914, 
xli,  588-590. 

5.  Heineck:  The  Modern  Operative  Treatment  of  Varicocele  of  the  Spermatic  Cord, 
Illinois  Med.  Jour.,  1910,  xviii,  551-569. 

6.  Istomin:  Zur   pathologischen   Histologie   und   Klinik   der   Varikokele,    Deutsch. 
Ztschr.  f.   Chir.,   1909,  xcix,   1-46. 

7.  Istomin:  Zur  Frage  der  operativen  Behandlung  der  Varikokele,  Zentralb.  f.  Chir., 
1914,  xli,  93-95. 

8.  Lameris:  Zur  Behandlung  der  Varikozele,  Miinchen.  med.  Wchnschr.,  1910,  Ivii, 
674-677. 

9.  Madden:  Lymphatic  Varicocele,  Lancet,  1912,  i,  17. 

10.  Mariani:  Blasenneuralgie  infolge  von  Varikokele,  Ztschr.  f.  Urol.,  1911,  v,  656. 

11.  Schwarz:  Der  Einfluss  der  Leiste  .auf  die  Varicocele,  Beitr.  z.  klin.  Chir.,  1910, 
Ixix,  547-568. 

12.  Van  Hook:  Varicocele  Operations,  Surg.,  Gynec.  and  Obst.,  1914,  xviii,  759. 

13.  Volpe:  Nuovo  metodo  di  cura  chirurgica  del  Varicocele,  Policlin,  Roma,   1910, 
xvii,    sez.    prat.,    227. 

14.  White:  Brit.  Med.  Jour.,  1914,  ii,  177. 

15.  Wolf:  Erfahrungen  mit  der  von  Nilson  angegebenen  Modifikation  der  Narathschen 
Varikozelenoperationen,  Deutsche  med.  Wchnschr.,  1912,  xxxviii,  1929-1932. 

16.  Zironi:  Contribute  clinico  al  trattemento  operative  del  Varicocele,  Clin.  Chir., 
Milano,  1911,  xix,  1215-1241. 

(See  modern  text-books.) 


CHAPTER  XV. 

INFECTIONS  OF  THE  TESTICLE. 
BY  J.  DELLINGER  BARNEY,  M.D. 

ACUTE  infections  of  the  testicle  as  compared  with  those  of  the 
epididymis  are  relatively  infrequent,  for,  as  Smith32  well  says :  "  It  is 
only  in  recent  years  that  differentiation  has  been  made  between 
processes  affecting  the  epididymis  and  those  affecting  the  testicle. 
Even  today  we  frequently  hear  of  'gonorrheal  orchitis'  when  epididy- 
mitis  is  the  real  disease." 

But  it  must  be  borne  in  mind  that  infection  of  the  testicle  proper, 
although  uncommon  as  compared  with  that  of  the  epididymis,  arises 
not  infrequently  as  a  complication  of  certain  of  the  infectious  diseases. 
These  diseases  are  typhoid  fever,  syphilis,  smallpox,  and  mumps; 
rarely  tonsillitis,  glanders,  dengue,  acute  articular  rheumatism,  malaria, 
gout,  scarlet  fever,  influenza,  and  typhus  fever.  In  the  presence  of  a 
septic  process  anywhere  in  the  body  (osteomyelitis)  abscess  of  the 
testicle  may  occasionally  arise,  while  a  few  cases  have  been  reported 
of  infection  by  the  colon  bacillus,  the  Bacillus  mucosus  capsulatus, 
and  the  Staphylococcus  aureus  and  albus  whose  source  could  not  be 
determined. 

Etiology. — An  inquiry  into  the  frequency  with  which  the  testicle  is 
attacked  in  the  various  infections  already  enumerated  shows  that  in 
proportion  to  the  number  of  cases  of  the  disease  these  testicular 
infections  are  rare. 

Pike,26  in  1911,  collected  from  the  literature  102  cases  of  orchitis  of 
typhoid  origin.  McCrae24  found  only  4  in  a  series  of  1500  cases  (0.27 
per  cent.),  while  in  a  total  of  5500  cases  of  typhoid  fever,  the  combined 
statistics  of  Osier,25  Liebermeister,23  Sorel,33  and  Holscher,14  the  testicle 
was  involved  but  14  times  (0.25  per  cent.).  On  the  other  hand,  Pierre 
Do18  found  no  instance  of  epididymo-orchitis  among  14,738  cases  of 
typhoid  fever  collected  from  French  and  German  sources. 

The  severity  of  the  typhoid  fever  has  no  relation  to  the  incidence  of 
orchitis.  It  usually  arises  early  in  the  course  of  convalescence,  may 
attack  a  patient  of  any  age  (usually  the  young  adult),  and  in  most  cases 
involves  both  testicle  and  epididymis.  Beardsley,3  in  102  cases,  found 
both  sides  involved  in  3;  when  unilateral,  the  right  side  was  affected 
more  often  than  the  left.  Suppuration  occurred  in  22  of  the  102  cases. 
In  13  suppurating  testicles  reported  by  Kinnicutt19  a  pure  culture  of  the 
typhoid  bacillus  was  grown  from  the  pus.  Symptomatic  hydrocele  is 
not  infrequent. 

(485) 


486 

Syphilis  of  the  testicle  (gumma)  is  said  to  be  uncommon  and  will 
probably  become  more  so  owing  to  improved  methods  of  treating  the 
disease.  Keyes,17  in  2170,  syphilitics  found  the  testicle  involved  only 
67  times,  of  which  but  10  wrere  bilateral.  While  I  have  no  definite 
statistics  of  these  cases,  I  believe  them  to  be  more  numerous  than  this. 
The  testicle  alone  is  affected  in  a  small  majority,  in  others  the  epi- 
didymis  shares  the  infection.  Suppuration  of  the  gummatous  testicle 
is  rare,  but  necrosis  may  occur  from  endarteritis. 

Acute  orchitis  as  a  complication  of  smallpox  (variola)  and  due  to 
secondary  pyogenic  infection  has  long  been  recognized,  but  its  incidence 
as  given  by  different  writers  seems  to  vary  widely.  It  seems  to  occur 
both  before  and  after  puberty.  Thus,  Roger30  found  48  infected  tes- 
ticles out  of  55  in  patients  dying  from  smallpox,  while  Quenu29  says  that 
in  severe  forms  of  the  disease  the  testicle  is  left  intact  only  once  in  ten 
times.  On  the  other  hand,  Hare  and  Beardsley13  observe  that  "  orchitis, 
single  or  double,  and  usually  accompanied  by  an  effusion  of  fluid  into 
the  tunica  vaginalis,  is  a  rare  complication  of  variola."  Welch  and 
Schamberg37  observed  this  complication  but  8  times  in  2000  cases  of 
variola.  It  is  probable  that  the  virulence  of  the  epidemic,  the  method 
of  treatment,  and  the  fact  of  vaccination  are  factors  which  would  influ- 
ence the  incidence  of  this  complication. 

The  orchitis  of  epidemic  parotitis  (mumps)  is  of  frequent  occurrence 
in  the  adult,  and  may  occasionally  occur  before  puberty.  The  well- 
known  study  of  Laveran  and  Catrin21  shows  that  it  is  likely  to  occur 
once  in  every  3  cases  of  mumps.  In  43  cases  it  was  bilateral  in  13,  on 
the  right  side  in  18,  and  on  the  left  side  in  12.  Osier25  records  211 
instances  in  699  cases  of  mumps.  The  frequency  of  orchitis  in  a  disease 
which  is  so  common  and  otherwise  so  comparatively  mild,  the  large 
proportion  of  bilateral  cases,  and  the  almost  certain  destruction  of  the 
spermatogenetic  function  of  the  organ  warrants  serious  consideration. 
Acute  orchitis  is  mentioned  in  the  text-books  as  an  occasional  com- 
plication of  glanders,  influenza,  dengue,  acute  articular  rheumatism, 
malaria,  scarlet  fever,  and  typhus  fever.  I  have,  however,  seen  no 
record  of  a  definite  case. 

Such  a  complication  in  tonsillitis  was  long  ago  recognized  by  Ver- 
neuil35  and  later  carefully  discussed  by  Lasegue.20  Joal,16  in  1886, 
reported  4  cases  and  went  with  great  thoroughness  into  the  relationship 
between  tonsillitis  and  epididymo-orchitis.  Occasional  instances  of 
this  rare  complication  of  tonsillitis  have  been  reported  from  time  to 
time,  the  most  recent  being  that  of  Prouty.28 

Septic  foci,  such  as  furunculosis  and  osteomyelitis  may  occasionally 
give  rise  to  an  acute  epididymo-orchitis,  a  case  of  the  former  being 
reported  by  Quenu,29  while  Biland5  records  a  similar  complication  in 
osteomyelitis  of  the  acromion  process.  The  rarity  of  an  orchitis  from 
this  source  may  be  judged  from  the  fact  that  I  have  found  no  other  cases 
of  it  in  the  literature. 

Finally,  there  are  on  record  a  very  few  cases  of  what  may  be  called 
"idiopathic"  orchitis  with  infection  by  a  pyogenic  organism  in  the 


PATHOLOGY  AND  PATHOGENESIS  487 

absence  of  any  demonstrable  focus.  Du  Bois8  reports  such  a  case  of 
staphylococcus  infection,  and  LeFur22  tells  us  of  another.  I1  have 
already  reported  3  such  cases  and  more  recently  have  operated  upon  a 
fourth.  My  colleague,  Smith,  has  also  met  with  one  within  the  year, 
at  the  Massachusetts  General  Hospital.  In  2  of  my  own  cases  the 
colon  bacillus  was  found  in  pure  culture.  In  another  the  Bacillus 
mucosus  capsulatus  was  the  offender,  with  a  few  streptococci  sprinkled 
in.  Cultures  from  the  other  cases  were  unsatisfactory. 

It  is  therefore  clear  that  almost  any  organism  in  the  blood  stream 
may  enter  the  testicle  and  may,  under  favorable  conditions  for  growth, 
produce  its  characteristic  lesions. 

Pathology  and  Pathogenesis. — It  is  well  known  that  the  animal 
organism  combats  bacilluria  by  elimination  of  the  bacteria  in  the 
circulating  blood  through  the  glands,  chiefly  kidneys,  but  we  also  know 
that  the  salivary  glands  (Quenu29),  the  seminal  vesicles  (Huet15),  and 
other  organs  may  share  in  this  work.  That  the  human  testicle  may  also 
assume  this  excretory  function  has  been  shown  by  Belfield4  who  says  : 
"  While  the  kidney  is  provided  with  a  new  and  private  sewer,  the  ureter, 
the  testis  continues  to  use  the  frog's  old  urinary  duct,  now  called 
epididymis  and  vas  deferens.  This  excretory  function  of  the  testicle 
and  its  duct  illumines  both  its  intimate  alliance  writh  the  kidney  and  its 
frequent  infection  from  the  blood.  The  recognition  of  the  testicle  as 
an  excretory  organ  illumines  the  frequent  invasion  of  its  tubules  by 
mumps,  typhoid  and  colon  bacilli,  Spirochseta  pallida  and  other  blood 
infections."  Be  it  further  noted  that  the  testicle  and  other  organs  may 
assume  this  excretory  role  without  damage  to  their  epithelium  (von 
Biede  and  Kraus36),  and  when  pathological  changes  occur,  they  must 
be  regarded  as  an  index  either  of  an  unusual  virulence  of  the  organisms, 
or  of  a  lowered  resistance  on  the  part  of  the  gland. 

While  we  have  already  seen  that  the  testicular  tissue  is  favorable  for 
the  growth  of  the  typhoid  bacillus,  the  Spirochaeta  pallida,  and  pyogenic 
bacteria,  as  well  as  for  certain  other,  as  yet  unknown,  organisms  (e.  g., 
that  of  mumps),  it  is  common  knowledge  that  the  gonococcus  rarely,  if 
ever,  finds  lodgment  in  this  organ,  and  the  tubercle  bacillus  (with  very 
rare  exceptions)  only  after  a  primary  invasion  of  the  epididymis.  For 
an  explanation  of  this  phenomenon  we  must  ascribe  to  the  testicle  not 
only  an  excretory,  but  also  a  selective  function.  It  is  well  established 
that  organisms  of  various  types  may  and  do  circulate  in  the  blood 
stream  at  various  times.  It  is  clear  that  these  organisms  must  find 
their  wray  into  the  testis  and  epididymis  as  freely  and  as  frequently  as 
into  other  organs;  perhaps  more  so,  owing  to  their  common  blood 
supply,  the  spermatic  arteries,  which  take  origin  from  the  aorta.  This 
has  been  demonstrated  by  Pique  and  Worms27  in  a  large  series  of  careful 
dissections  of  injected  human  specimens  (Figs.  215. 216  and  217).  They 
have  shown  constant  but  slightly  variable  anastomoses  between  the 
spermatic,  the  deferential,  and  the  funicular  arteries  (the  latter  running 
in  the  walls  of  the  tunica  vaginalis) .  It  is  thus  seen  that  bacteria  reach 
the  testicle  and  epididymis  with  equal  facility.  While  the  comparative 


488 


INFECTIONS  OF  THE  TESTICLE 


FIG.  215.  —  Type  I.  1,  spermatic 
artery;  2,  epididymal  branch  of  the 
spermatic;  3,  deferential  artery;  4, 
funicular  artery;  5,  epididymo-funiculo- 
deferential  anastomosis  in  form  of  T. 
(From  Picque  and  Worms,  loc.  cit.) 


FIG.  216.  —  Type  II.     1,   spermatic 

artery  (main  trunk);  2,  internal  sper- 
matic artery;  3,  external  spermatic 
artery;  4,  epididymal  branch;  o,  defer- 
ential artery;  7,  spermato-funiculo- 
deferential  anastomosis  in  form  of  T. 


FIG.  217. Type  III.  1,  spermatic  artery;  8,  epididymal  branch  of  spermatic  artery; 

-3,  deferential  artery;  4,  funicular  artery;  5,  anastomosis  between  epididymal  branch  and 
deferential  artery ;  6,  anastomosis  between  a  testicular  branch  of  spermatic  and  funicular 
artery. 


PATHOLOGY  AND  PATHOGENESIS  489 

infrequency  of  orchitis  as  compared  with  epididymitis  is  undoubtedly 
due  very  largely  to  the  fact  that  the  testicle,  as  Belfield4  has  shown, 
excretes  the  bacteria  which  enter  it  into  the  epididymis,  there,  are  two 
other  factors  which  undoubtedly  contribute  to  its  comparative  im- 
munity from  infection.  These  are: 

First,  the  tunica  albuginea  whose  protective  value  was  long  ago 
recognized  by  Grendin.12  He  says:  "When  the  contiguous  organ  or 
adjacent  part  is  of  a  different  structure  from  that  of  the  cellular  tissue, 
the  extension  of  the  inflammation  inward  is  checked.  Thus  in  the  case 
of  the  inflamed  tunica  vaginalis  the  cellular  tissue  readily  transmits  the 
morbid  action  to  the  epididymis,  but  the  tunica  albuginea  arrests  its 
progress  to  the  body  of  the  testicle." 

Second,  Testut34  and  others  have  pointed  out  that  the  testicle  is 
surrounded  and  permeated  by  a  very  rich  lymphatic  network,  much 
greater  than  that  enjoyed  by  the  epididymis. 

Furthermore,  the  elaborate  blood  supply,  already  mentioned,  while 
serving  as  a  path  along  which  bacteria  can  travel,  undoubtedly  serves 
at  the  same  time  as  a  highly  efficient  means  of  defense. 

In  most  testicular  infections  it  is  obvious  that  the  organisms  travel 
by  way  of  the  blood  stream.  This  would  hold  true  in  general  systemic 
diseases  such  as  typhoid  fever,  or  in  pyogenic  septicemia  (from  furuncu- 
losis  or  osteomyelitis,  for  example).  In  certain  other  cases  the  vas 
deferens  or  the  lymphatics  of  the  spermatic  cord  must  be  held  account- 
able for  the  transmission  of  organisms. 

This  hypothesis  would  apply  particularly  to  the  cases  with  preexist- 
ing inflammation  of  the  organs  at  the  bladder  neck  or  of  the  urethra, 
as  in  a  case  recorded  by  Dalous7  and  in  two  of  my  own  cases.  The 
researches  of  many,  especially  Baumgarten,2  have  shown  that  infections 
travel  usually  with  the  stream  of  the  secretion  of  the  organ  involved. 
While  there  are  exceptions  to  this  rule,  with  reversal  of  peristalsis  in  the 
vas  deferens,  it  is  evident  that  it  furnishes,  in  most  cases,  ample  ground 
for  the  elimination  of  this  structure  as  a  path  along  which  organisms 
can  travel. 

There  is  left,  then,  the  possibility  of  a  lympnangitis  or  of  a  phlebitis. 
While  a  retrograde  lymphangitis  is  certainly  an  uncommon  phenome- 
non, Dalous7  and  Quenu29  are  in  agreement  that  it  can  occur,  especially 
in  the  spermatic  cord  and  testicle,  and  they  further  observe  that  it  may 
take  place  without  the  usual  clinical  manifestations  of  its  presence. 
Whether  a  phlebitis,  transmitting  its  infection  to  the  testicle,  can  be 
held  accountable  for  these  infections  is  open  to  argument.  There 
appears  to  be  no  definite  proof  that  it  occurs.  The  fact  remains  that  in 
gonorrheal  epididymitis  it  is  not  unusual  to  observe  pain,  tenderness, 
and  induration  of  the  spermatic  cord  slowly  progressing  from  groin  to 
epididymis,  and  Kinnicutt18  describes  a  similar  order  of  events  in  a  case 
of  typhoidal  epididymo-orchitis. 

On  the  other  hand,  there  are  several  examples  of  transmission  of  the 
infection  from  testicle  to  bladder  and  urethra,  probably  through  the 
vas  deferens.  Thus  in  one  of  my  cases  the  urine  at  first  was  clear  and 


490  INFECTIONS  OF   THE   TESTICLE 

sterile  to  culture.  Several  days  after  orchidectomy  there  appeared  a 
urethral  discharge  together  with  cloudy  urine.  Cultures  showed  the 
same  organism  as  was  found  in  the  testicular  abscess.  This  experience 
coincides  with  that  of  other  observers.  These  data  furnish  additional 
proof  of  the  excretory  function  of  the  testicle,  which,  by  eliminating 
organisms  through  epididymis  and  vas  deferens,  infected  the  urethra 
and  bladder  neck. 

Pathology. — The  pathology  of  testicular  infections  has  been  com- 
paratively little  studied.  Smith31  in  a  recent  article  describes  a  case  of 
epididymo-orchitis  of  typhoid  fever  operated  upon  by  Cabot.  The 
former  says :  "  There  was  ja  small  amount  of  free  fluid  within  the  tunica 
and  a  gelatinous  exudate  covered  the  testicle.  The  epididymis  was 
enlarged  to  four  or  five  times  its  normal  girth,  was  tense  and  hard,  and 
in  color  a  reddish  purple.  The  testicle  was  of  normal  size,  and  in  its 
upper  two-thirds  of  normal  color.  The  lowest  third,  which  was  sepa- 
rated from  the  upper  portion  by  a  sharp  line  of  demarcation,  was  slightly 
swollen  and  of  a  darker  color.  A  nick  was  made  through  the  tunica 
albuginea  of  this  part  of  the  testicle;  the  underlying  tissue  was  dry 
and  did  not  bleed.  No  pus  was  obtained  (from  the  epididymis)  but  the 
serous  fluid  which  oozed  from  the  punctures  showed  a  pure  culture  of 
the  typhoid  bacillus.  The  involvement  of  the  testicle  was  caused 
by  the  occlusion  of  its  arterial  supply  (the  capsular  artery,  a  branch 
of  the  spermatic,  which  pierces  the  tunica  albuginea  close  to  the 
epididymis)." 

There  seems  to  be  no  good  description  of  such  infections  of  the  testicle 
which  have  suppurated,  but  Girode10  has  shown  that  the  suppuration  is 
between,  not  within,  the  canaliculi. 

The  pathology  of  syphilitic  infection  of  the  testicle  and  epididymis  is 
that  of  gumma,  plus  the  changes  wrought  by  interstitial  sclerosis  in  the 
seminiferous  tubules.  These  are  destroyed  to  a  greater  or  less  extent 
by  the  sclerotic  changes,  but  after  an  arrest  of  the  syphilitic  process 
show  a  marked  recuperative  power. 

For  the  pathology  of  the  orchitis  of  mumps  we  are  again  indebted  to 
Smith,31  who  recently  operated  upon  two  such  testicles.  The  tunica 
vaginalis  was  opened  "with  escape  of  about  one  ounce  of  turbid  yellow 
fluid.  The  testicle  was  three  times  the  size  of  a  normal  testicle,  firm  and 
elastic  on  palpation.  The  color  was  more  bluish  than  is  usual,  and 
throughout  the  tunica  albuginea  were  scattered  many  minute  reddish 
specks,  probably  punctate  hemorrhages.  The  epididymis  was  defin- 
itely enlarged,  soft,  without  induration,  and  of  a  deep  red  color  which  at 
the  globus  major  became  almost  black.  The  cord  was  somewhat  ede- 
matous,  the  vas  normal."  A  second  case  presented  "  an  almost  iden- 
tical picture."  Small  sections  of  these  testicles  were  examined  by 
Dr.  S.  B.  Wolbach,  associate  professor  of  bacteriology  in  the  Harvard 
Medical  School.  He  says:  "The  process  does  not  affect  the  testicle 
tissue  uniformly.  There  are  groups  of  seminiferous  (convoluted) 
tubules  which  are  completely  destroyed  and  distended  with  exudate, 
separated  by  areas  of  normal  and  slightly  affected  tubules  which  contain 


PATHOLOGY  491 

large  numbers  of  mitotic  sexual  cells,  though  few  mature  sperma- 
tozoa. 

"The  exudate  in  the  destroyed  tubules  consists  chiefly  of  poly- 
morphonuclear  leukocytes  and  phagocytic  endothelial  leukocytes.  The 
cells  of  the  tubules  have  mostly  undergone  a  hyaline  degeneration  and 
are  taken  up  by  phagocytic  endothelial  leukocytes,  though  there  are 
occasionally  perfectly  preserved  mitotic  sexual  cells  scattered  among  the 
tightly  packed  exudative  cells. 

"The  intertubular  connective  tissue  everywhere  is  edematous  and 
between  the  tubules  most  affected  contains  coarse,  meshed  fibrin,  small 
areas  of  hemorrhage  and  many  polymorphonuclear  leukocytes  and 
endothelial  leukocytes. 

"Among  the  groups  of  least  affected  tubules  there  are  some  with 
normal  epithelium,  but  with  lumina  partly  filled  with  polymorpho- 
nuclear and  endothelial  leukocytes,  as  if  the  process  was  spreading 
along  the  lumina. 

"  There  are  many  more  tubules,  however,  which  show  lesions  involv- 
ing a  small  portion  of  the  circumference,  where  it  appears  as  if  the 
process  was  extending  from  the  intertubular  connective  tissue.  In 
these  places  numerous  leukocytes  are  found  in  the  act  of  migrating 
through  the  basement  membrane  of  the  tubules.  These  small  lesions 
contain  deeply  staining  hyaline  degenerated  sexual  cells,  hyaline  frag- 
ments, polymorphonuclear  leukocytes  and  endothelial  leukocytes.  The 
immediately  adjacent  epithelium  is  usually  full  of  mitotic  sexual  cells 
showing  the  various  stages  of  spermatogenesis. 

"The  tunica  albuginea  is  edematous,  and  there  are  small  hemorrhages 
and  zones  of  cellular  exudate  about  bloodvessels.  The  cells  about  blood- 
vessels are  polymorphonuclear  leukocytes  and  endothelial  leukocytes. 

"Mitotic  endothelial  cells  in  the  lumina  of  capillaries  occur  in  the 
tunica  albuginea  and  intertubular  connective  tissue. 

"Liquefaction  necrosis  is  not  present  either  in  the  tubules  or  in  the 
connective  structures. 

"  No  bacteria  or  other  parasites  can  be  found  in  the  sections  and  in 
film  preparations  made  at  the  time  of  operation." 

In  both  cases  the  blood  cultures  and  the  cultures  from  the  hydrocele 
fluid  and  testicular  tissue  were  bacteriologically  negative. 

Thanks  to  Councilman,24  we  have  an  admirable  description  of  the 
pathology  of  the  testicle  in  smallpox,  which  I  quote  at  length. 

"Lesions  most  difficult  of  interpretation  are  those  of  the  testicle. 
There  is  absence  of  spermatogenesis  in  the  cases  in  which  convalescence 
is  established.  Normal  spermatozoa  are  absent  in  the  lumina  of  the 
tubules,  and  there  is  degeneration  of  the  spermatogenetic  cells.  This 
affects  both  cytoplasm  and  nuclei  and  the  degenerating  nucleus  assumes 
forms  which  present  some  similarity  to  certain  of  the  intracellular  para- 
sites in  the  epithelial  cells  of  the  skin.  This  degeneration  is  not  peculiar 
to  smallpox  but  may  be  found  in  typhoid  fever.  These  lesions  are 
absent  in  the  undeveloped  testes  of  children. 

"In  addition  to  diffuse  degenerative  lesions  there  are  focal  lesions  as 


492  IXFECTIOXS  OF  THE   TESTICLE 

characteristic  of  the  disease  as  the  skin  lesions  found  in  adult  and 
child's  testes.  Lesions  begin  as  an  infiltration  of  the  intertubular  tissue 
with  both  ordinary  lymphoid  cells  and  large  mononuclear  basophilic 
cells.  The  tubules  in  the  foci  are  unaltered.  From  such  lesions  as 
these,  which  are  best  compared  with  small  interstitial  foci  in  the  kid- 
neys, the  process  extends.  The  area  enlarges,  the  cellular  infiltration 
extends  and  finally  there  is  complete  necrosis  in  the  centre,  with  fibrin 
and  hemorrhage  in  the  surrounding  interstitial  tissue.  The  necrotic 
tubules  often  contain  numbers  of  phagocytic  cells.  The  bloodvessels 
in  the  foci  are  obliterated  in  some  cases  by  thrombi,  but  chiefly  by  the 
pressure  of  the  cells.  Acute  endarteritis  with  accumulations  of  mono- 
nuclear  cells  is  often  found. 

"  The  lesions  vary  in  number,  some  testicles  showing  large  numbers 
of  them,  while  in  others  they  are  found  only  after  prolonged  search. 
The  smallest  lesions  and  those  best  adapted  for  study  are  in  the  un- 
developed testes  of  children.  They  show  a  general  relation  to  the 
duration  of  the  disease,  the  most  advanced  cases  occurring  late  in 
the  course. 

"  Notwithstanding  its  apparently  specific  nature  no  parasites  were 
found  in  the  testicular  lesions  of  man." 

Secondary  infection  of  the  smallpox  testicle,  at  least  in  the  suppura- 
tive  cases  is  exceedingly  common,  for  Esmonet,9  in  a  number  of  such 
cases,  found  streptococci,  pneumococci,  colon  bacilli,  and  the  Staprrylo- 
coccus  aureus  alone  or  associated  with  the  streptococcus. 

The  pathology  of  suppuration  of  the  testicle,  when  due  to  pyogenic 
infection,  is  not  peculiar,  but  it  is  fair  to  say  that  there  is  little  available 
material  on  which  to  base  an  opinion.  In  a  case  operated  upon  by  me, 
with  infection  by  the  Bacillus  mucosus  capsulatus  and  the  streptococcus, 
practically  the  whole  testicle  was  occupied  by  an  abscess  cavity  (Fig. 
218).  Sections  of  this  testicle,  examined  for  me  by  Prof.  S.  B.  \Yolbach, 
showed  that  necrosis  had  "extended  irregularly  into  the  substance  of 
the  testicle,  following  the  interstitial  tissue."  In  a  second  personal 
case,  of  colon  bacillus  origin,  the  abscess  was  found  to  occupy  only  the 
upper  third  of  the  organ,  there  being  a  fairly  sharp  line  of  demarca- 
tion between  this  and  the  rest  of  the  testicle  which  was  but  little  affected. 
In  still  a  third  case,  only  the  lower  third  of  the  testicle  was  involved 
in  the  abscess.  The  normal-looking  upper  two-thirds  of  the  organ  was 
left  behind,  but  became  necrotic  and  sloughed  out  later.  In  a  fourth 
orchidectomy  (a  recent  case,  unreported)  I  found  a  comparatively  early 
stage  of  the  infection.  The  whole  testicle  was  riddled  with  abscesses 
of  varying  size,  with  tufts  of  seminiferous  tubules  sticking  out  here  and 
there  through  holes  in  the  tunica  albuginea  (Fig.  219).  A  testicle  very 
similar  to  this,  with  Staphylococcus  aureus  infection,  has  been  described 
by  Dalous.7 

I  have  been  unable  to  find  descriptions  of  the  orchitis  which  is  said 
to  occur  in  influenza,  glanders  and  other  infectious  diseases,  but  it 
seems  unlikely  that  their  pathology  offers  any  peculiarities. 

From  the  foregoing  consideration  of  the  etiological  factors,  of  the 


PATHOLOGY 


493 


A- 


FIG.  218. — Abscess  of  testicle.  Mucosus  capsulatus.  Author's  case.  A,  thick- 
ened tunica;  B,  remains  of  wall  of  testicle;  C,  abscess  cavity  in  testicle;  D,  epididymis. 
Anterior  view. 


FIG.  219. — Abscess  of  testicle.  No  culture.  Author's  case.  A,  A,  A,  tufts  of 
seminiferous  tubules  protruding  through  tunica  albuginea;  B,  hydatid  of  Morgagni; 
C,  epididymis.  Lateral  view. 


494  INFECTIONS  OF  THE  TESTICLE 

probable  paths  of  infection,  and  of  the  pathology  it  is  possible  to  state 
that  acute  orchitis  can  occur  under  three  different  conditions: 

1.  As  a  localization  of  a  primary  infection  (mumps,  typhoid,  syphilis, 
pyogenic  septicemia,  etc.). 

2.  As  a  localization  of  a  secondary  infection  in  one  of  the  above 
conditions. 

3.  As  a  propagation  of  a  urethritis  primary  or  secondary  to  a  pyo- 
genic infection  of  the  prostate,  urethra,  or  bladder  neck. 

It  must  not  be  forgotten,  however,  that  a-  severe  orchitis  may  be  the 
result,  not  of  actual  bacterial  invasion  of  the  organ,  but  of  a  bacterial 
toxemia.  The  possibility  of  this  has  been  demonstrated  by  Esmonet,9 
who  produced  total  necrosis  of  the  testicle  (in  dogs)  by  the  injection  of 
15  drops  of  typhoid  toxins.  Also  in  thirteen  suppurating  testicles  of 
typhoidal  origin  Kinnicutt18  found  a  sterile  culture  in  six.  Similar 
findings  are  reported  in  mumps  (Smith32)  and  in  smallpox  (Council- 
man6). 

Symptomatology  and  Diagnosis. — These  two  aspects  of  acute  epi- 
didymo-orchitis  can  be  considered  together. 

In  syphilis  of  the  testicle  the  onset  is  gradual  and  generally  symptom- 
less,  the  patient  seeking  advice  largely  because  of  the  enlargement  of 
the  scrotum.  The  unilateral,  wood-like  hardness,  involving  chiefly  the 
testicle,  the  complete  absence  of  normal  testicular  sensation  (an  im- 
portant point),  and  lack  of  tenderness,  the  irregular  contour,  should 
suggest  gumma  at  once.  These  findings,  together  with  a  positive 
Wassermann  reaction  in  the  blood  or  cerebrospinal  fluid,  or  other 
evidences  of  syphilis,  should  make  the  diagnosis  clear.  The  diagnosis 
is  established  occasionally  only  by  exploratory  incision. 

The  symptoms  of  practically  every  other  form  of  orchitis  are  those  of 
acute  inflammation  localized  to  this  organ  or  at  least  to  the  scrotum. 
The  onset  may  be  sudden  and  the  pain  intense,  concentrating  in  the 
testicle  or  possibly  radiating  to  the  groin,  back  or  perineum.  In  certain 
cases  there  is  marked  constitutional  disturbance  aside  from  that  occa- 
sioned by  the  general  infection  from  which  the  patient  suffers.  The 
temperature  may  be  considerably  elevated  (102°  to  103°  F.)  and  nausea 
and  vomiting  may  accompany  the  attack.  In  certain  cases  an  accumu- 
lation of  hydrocele  fluid  may  make  the  differentiation  between  orchitis 
and  epididymitis  obscure;  in  others  palpation  will  show  a  much  en- 
larged, tender  testicle,  smooth  and  firm,  with  an  epididymis  more  or 
less  involved.  In  the  later  stages  the  skin  of  the  much  enlarged  scrotum 
may  be  red,  edematous,  or  in  a  state  of  phlegmon,  with  distinct  fluctua- 
tion concentrated  especially  on  its  anterior  surface.  The  whole  sper- 
matic cord  may  be  traced  into  the  groin  as  a  much  enlarged  conglomera- 
tion of  vas,  vessels,  and  cremaster  muscle,  indurated  and  tender  to  the 
touch.  The  prostate  and  vesicles  may  or  may  not  be  inflamed,  and 
urethritis  (in  which  organisms  other  than  the  gonococcus  may  be 
demonstrated)  may  exist.  The  urine  may  be  clear  and  sterile  to 
culture.  It  may,  on  the  other  hand,  contain  pus  together  with  the 
organisms  of  either  of  the  general  infection  (typhoid,  for  example)  or  of 


PROGNOSIS  495 

the  scrotal  infection  (as  in  a  case  of  infection  with  Staphylococcus  aureus 
reported  by  Quenu29) .  Accompanying  these  phenomena  there  may  be 
the  symptoms  of  bladder  irritability. 

A  diagnosis  of  the  cause  of  infection  will  depend  upon  circumstances. 
In  the  presence  of  parotitis  (which  incidentally  may  be  easily  over- 
looked), in  the  event  of  smallpox,  typhoid  fever,  or  any  other  definite 
general  infection  the  nature  of  the  orchitis  will  be  clear.  One  also 
would  have  suspicion  aroused  if  the  orchitis  arose  in  the  course  of 
tonsillitis  or  of  some  localized  pyogenic  infection. 

On  the  other  hand,  one  must  not  forget  that  orchitis  may  appear 
spontaneously  in  a  previously  healthy  individual,  as  in  the  case  of 
Du  Boiss  and  of  Le  Fur22  and  in  those  reported  by  the  writer.1 

Some  difficulty  might  be  encountered  at  the  onset  in  differentiating 
between  a  torsion  of  the  testicle  and  an  orchitis.  What  begins  as  a 
torsion  may  rarely  become  an  orchitis,  owing  to  the  interference  with 
the  circulation  of  the  testicle  and  its  subsequent  invasion  by  bacteria. 
Exploratory  incision  or  the  gradual  decrease  of  symptoms  under  pallia- 
tive treatment,  with  atrophy  of  the  testicle,  will  generally  differentiate 
the  two  conditions. 

Prognosis. — The  prognosis  in  acute  orchitis  may  be  divided  into 
that  for  the  patient,  and  that  for  the  testicle  involved,  with  a  pos- 
sible subdivision  which  takes  the  other  half  of  the  scrotum  into  con- 
sideration. 

The  outlook  for  the  patient  himself  depends  upon  the  nature  of  his 
infection.  In  typhoid  fever,  mumps,  smallpox,  syphilis  or  any  other 
general  infection,  the  mortality  seems  to  be  not  at  all  influenced  by  the 
intervention  of  an  orchitis.  I  have  also  seen  no  account  of  a  death 
following  orchitis  when  due  to  pyogenic  organisms,  whether  primary  or 
secondary. 

The  chances  of  saving  the  testicle  vary  also  with  the  kind  of  infection, 
and  must  be  considered  from  the  stand-point  of  spermatogenesis,  as  well 
as  from  that  of  internal  secretion.  If  extensive  suppuration  has  taken 
place  orchidectomy  will  be  necessary.  In  certain  cases  evacuation  of 
the  pus  by  trocar  or  simple  incision  may  suffice.  It  is  to  be  expected, 
however,  that  the  remaining  portions  of  the  testicle  will  eventually 
become  so  atrophied  as  to  be  of  little  or  no  value  to  the  patient  except 
possibly  from  a  psychic  stand-point. 

In  typhoid  fever  the  combined  statistics  of  Kinnicutt18  and  of  Hare  and 
Beardsley13  show  an  incidence  of  suppuration  of  22.5  per  cent.  The 
percentage  of  bilateral  orchitis  is  very  small  (Kinnicutt  0.42  per  cent., 
and  Hare  and  Beardsley  0.44  per  cent.).  When  suppuration  does  not 
occur,  atrophy,  more  or  less  complete,  is  to  be  expected,  writh  a  conse- 
quent destruction  of  the  functional  activities,  especially  spermato- 
genesis, of  the  organ.  Smith31  has  recently  shown  us  that  this  is  due 
to  a  destruction  of  the  arterial  supply  of  one  or  another  portion  of  the 
testicle.  His  case  also  suggests  the  desirability  of  drainage  at  an  early 
stage  of  the  infection. 

In  mumps  we  have  seen  that  orchitis  occurs  once  in  about  every 


496  IXFECTIOXS  OF  THE  TESTICLE 

three  cases.  Laveran  and  Catrin21  show  a  bilaterality  of  30  per  cent., 
and  a  subsequent  atrophy  of  60  per  cent,  of  the  testicles  so  affected. 
Secondary  infection  does  not  seem  to  be  mentioned.  Smith's  recent 
work32  in  this  affection  suggests  that  the  subsequent  atrophy,  which 
completely  destroys  the  sexual  function  of  the  gland,  may  be  obviated 
or  lessened  by  early  operation.  It  has  been  shown  that  the  testicle  is 
attacked  by  the  Spirochseta  pallida  rather  infrequently  (67  times  in  2170 
cases,  Keyes17),  and  both  sides  are  affected  in  6.7  per  cent.  With  proper 
antisyphilitic  treatment  the  future  of  the  testicle  seems  to  be  bright,  for 
we  have  the  word  of  Gosselin11  that  spermatozoa  have  been  found  in  the 
semen  after  such  treatment.  Also  in  the  words  of  Keyes,17  "Whatever 
part  of  the  parenchyma  has  not  been  destroyed  by  sclerosis  will  con- 
tinue to  functionate,  and  the  testicle  which  has  been  syphilitic  for 
years  may  still  secrete  spermatozoa."  Secondary  infection  is  not  to 
be  expected. 

There  seem  to  be  no  actual  figures  at  hand  as  to  the  frequency  of 
suppuration  in  the  orchitis  of  smallpox,  but  if  we  are  to  believe  Es- 
monet,9  secondary  infection  is  not  uncommon.  We  are  also  left  in  the 
dark  as  to  the  probability  of  bilateral  infection.  The  minute  patholog- 
ical picture  of  these  testicles  painted  for  us  by  Councilman6  and  the 
apparent  frequency  of  suppurative  processes  make  the  prognosis  of 
such  an  orchitis  bad  from  every  point  of  view. 

Pyogenic  infection  of  the  testicle,  primary  or  secondary,  apart  from 
the  diseases  already  enumerated,  seems  never  to  be  bilateral.  Destruc- 
tion of  the  gland  is  generally  so  complete  as  to  require  its  removal. 
Even  successful  attempts  at  conservation  will  leave  behind  only  a  small 
mass  of  scar  tissue. 

Treatment. — The  physician  must  be  guided  in  his  treatment  of  the 
case  by  local  and  general  conditions. 

In  typhoid  fever  and  mumps,  early  and  thorough  drainage  of  the 
tunical  sac  by  incision,  and  of  the  epididymis  and  testicle  by  multiple 
puncture,  may  be  considered  and,  in  certain  cases,  may  be  necessary. 
Palliative  treatment  will  probably  suffice  for  most  cases,  and  in  the 
absence  of  actual  suppuration  the  results  may  be  as  good  as  with 
drainage. 

In  the  far-advanced  cases  with  free  pus  and  much  tissue  destruction, 
orchidectomy  is  indicated. 

In  syphilis,  salvarsan  or  neosalvarsan  and  mercury  will  produce  good, 
often  brilliant  results.  The  knife  is  indicated  but  rarely. 

In  certain  mild  infections  of  the  testicle  the  time-honored  measures 
of  rest  in  bed,  an  ice-bag,  and  support  of  the  scrotum  by  a  suspensory 
or  an  Alexander  bandage  may  suffice. 

Combined  with  these  measures,  or  with  surgery,  the  patient  should  be 
given  some  urinary  antiseptic  (preferably  sandalwood  oil  or  hexa- 
methylenamin),  an  abundant  supply  of  liquids,  a  good  cathartic,  and  a 
light  diet. 

Meantime  if  he  is  suffering  from  one  of  the  general  infections  already 
mentioned  the  treatment  of  this  should  go  on  as  usual. 


BIBLIOGRAPHY  497 


BIBLIOGRAPHY. 

1.  Barney:  Surg.,  Gynec.  and  Obst.,  March,  1914. 

2.  Baumgarten:  Verhandl.  d.  deutsch.  path.  Gesellsch.,  1905. 

3.  Beardsley:  Jour.  Am.  Med.  Assn.,  March  28,  1908. 

4.  Belfield:  Jour.  Am.  Med.  Assn.,  October  19,  1912. 

5.  Biland:  Cent,  der  Harn.  und  Sexualkrankheiten,  1905. 

6.  Councilman:  Osier  and  McCrae's  Mod.  Med.,  1913,  2d  edition,  i. 

7.  Dalous:  Ann.  des  Mai.  des  Org.  Genito-urinaires,  1905,  ii. 

8.  Du  Bois:  Rev.  Med.  de  la  Suisse  Romande,  1909,  No.  11,  800. 

9.  Esmonet:  Th&se  de  Paris,  1903. 

10.  Girode:  Keen,  The  Surgical  Complications  of  Typhoid  Fever,  1898. 

11.  Gosselin:  Watson  and  Cunningham,  Dis.  and  Surg.  of  the  Genito-urinary  System, 
1908. 

12.  Grendin:  Curling,  Diseases  of  the  Testis,  3d  edition. 

13.  Hare  and  Beardsley:  Typhoid  Fever  and  Exanthemata,  Lea  &  Febiger,  Philadel- 
phia, 1909. 

14.  Holscher:  Mtinchen  med.  Wchnschr.,  1891,  Nos.  3  and  4. 

15.  Huet:  Cent.  f.  Bakt.,  1909,  Hi. 

16.  Joal:  Arch,  gen.  de  Med.,  1886. 

17.  Keyes:  Syphilis,  1908. 

is.  Kinnicutt:  Med.  Rec.,  1901,  lix. 

19.  Kinnicutt:  Med.  Rec.,  1901,  lix,  801. 

20.  Lasegue:  Traite  des  Angines,  Paris,  1868. 

21.  Laveran  and  Catrin:  Bull,  et  mem.  Soc.  Med.  des  hop.,  Paris,  1894,  xi,  108. 

22.  Le  Fur:  Bull.  Assn.  francaise  d'Urologie,  Paris,   1909. 

23.  Liebermeister:  Ziemssen's  Handbuch  d.  spec.  Path.  u.  Therap.,  1874,  ii,  Bd.  ii, 
189. 

24.  McCrae:  Osier  and  McCrae's  Mod.  Med.,  1912,  i,  2d  edition. 

25.  Osier:  Pract.  of  Med.,   1901,  4th  edition. 

26.  Pike:  Am.  Jour,  of  Dermat.  and  Genito-urinary  Diseases,  xv,  202. 

27.  Picque  and  Worms:  Jour,  de  1'Anat.  et  de  la  Phys.  norm,  et  path.,  1909,  i,  51. 

28.  Prouty:  Jour.  Am.  Med.  Assn.,  1912,  viii,  1192. 

29.  Quenu:  Presse  Med.,  1909,  xvii,  281. 

30.  Roger:  Esmonet,  These  de  Paris,  1903. 

31.  Smith:  Boston  Med.  and  Surg.  Jour.,  1912,  clxii,  No.  10,  323. 

32.  Smith:  Tr.  Am.  Urol.  Assn.,  1912,  vi. 

33.  Sorel:  Bull,  et  mem.  de  la  Soc.  med.  des  hop.,  Paris,  1889,  Ivi,  236. 

34.  Testut:  Traite  d'Anat,  Humaine,  Paris,  1897. 

35.  Verneuil:  Arch.   gen.   de  Med.,    1857. 

36.  Von  Biede  and  Kraus:  Zeit.  f.  Hyg.,  1898,  xxvi,  353. 

37.  Welch  and  Schamberg:  Acute  Contagious  Diseases,  1905. 


M  XT     i — 32 


CHAPTER  XVI. 
GENITAL  TUBERCULOSIS. 

BY  J.  BELLINGER  BARNEY,  M.D. 

Introduction. — Tuberculosis  of  the  genital  tract  in  the  male  com- 
mences in  the  epididymis.  Thence  it  spreads,  at  a  fairly  early  date, 
to  prostate  and  seminal  vesicles,  and,  in  some  cases,  attacks  the  testicle 
and  the  bladder.  The  vas  deferens  becomes  involved  to  a  greater  or 
less  extent  in  practically  all  cases.  It  is  a  characteristic  of  the  disease 
to  attack  the  opposite  epididymis  in  over  half  the  cases,  within  a  year 
or  two  of  the  time  of  involvement  of  the  first  side.  This  catastrophe 
occurs  in  spite  of  all  efforts  to  prevent  it,  but  early  excision  of  the 
epididymis  first  attacked  will  improve  the  chances  for  the  escape  of  its 
fellow. 

Primary  tuberculosis  of  the  prostate,  seminal  vesicle,  testicle,  penis 
and  urethra  is  occasionally  reported.  While  there  are  a  very  few  un- 
doubted examples  of  such  lesions,  most  of  those  reported  are  open  to 
criticism  and  can  be  disregarded. 

Genital,  tuberculosis  in  adults  is  found  in  from  2  to  5  per  cent,  of  all 
tuberculous  subjects.  It  is  much  less  frequent  in  children.  In  over 
50  per  cent,  of  cases  there  will  be  found  old  or  active  foci  in  other  organs, 
especially  the  lungs.  The  urinary  tract  is  often  involved  with  the 
genital  tract,  but  careful  inquiry  will  show  that  involvement  of  the  one 
system  preceded  that  of  the  other.  In  my  experience,  when  both  are 
diseased,  the  genital  tract  has  been  first  attacked. 

While  proof  is  lacking  of  the  exact  mode  of  onset  of  the  disease  in  the 
genital  tract,  it  seems  probable  that  the  tubercle  bacillus  reaches  the 
epididymis  by  way  of  the  blood  stream,  and  that  the  testicle  and  epi- 
didymis may  possess  an  excretory  function.  The  means  of  transmission 
of  the  disease  to  the  other  genital  organs  is  still  more  in  dispute.  It 
seems  probable  that  the  lymphatics,  especially  those  of  the  vas  deferens, 
serve  as  a  bridge  between  epididymis,  prostate,  and  seminal  vesicle. 
A  similar  route  is  probably  taken  from  epididymis  to  testicle.  Involve- 
ment of  the  second  epididymis  takes  place  in  the  same  way  as  that  of 
the  first  side,  or  by  the  transmission  of  the  bacilli  from  the  already  in- 
fected prostate  and  seminal  vesicle  through  the  lymphatics  of  the  second 
vas,  but  in  a  direction  opposite  to  that  of  the  normal  flow. 

The  pathological  features  of  tuberculosis  of  the  genital  tract  are  not 
essentially  different  from  those  of  the  disease  in  other  organs.  Its 
characteristics  are  marked  chronicity,  a  strong  tendency  to  sinus  forma- 
tion, and  a  gradual  replacement  of  the  normal  structures  by  dense 
connective  tissue. 
(498) 


INCIDENCE  OF  TUBERCULOSIS  499 

After  the  removal  of  one  or  both  epididymes  the  tuberculous  process 
in  the  prostate  and  seminal  vesicles  generally  becomes  quiescent  and  a 
clinical  cure  is  established. 

While  the  tubercle  bacillus  is  directly  responsible  for  the  disease, 
there  are  certain  contributing  factors  of  importance.  Trauma,  a  pre- 
vious infection  (generally  gonococcal),  and  ectopia  of  the  testicle  may 
serve  to  reduce  the  local  resistance.  The  young  adult  is  most  often 
attacked,  but  cases  have  been  reported  in  infants  on  the  one  hand,  and 
in  men  over  80  on  the  other. 

Most  cases  seek  treatment  within  6  months  of  the  supposed  onset  of 
the  disease,  but  its  beginnings  are  generally  so  ins:dious  that  the  onset 
is  difficult  to  determine.  Affections  of  the  second  epididymis  occur  in 
from  40  to  75  per  cent,  of  all  cases,  while  the  prostate  and  seminal 
vesicles  are  attacked  in  at  least  75  per  cent. 

It  will  be  found  that  most  patients  have  lost  weight,  owing,  no  doubt, 
to  the  involvement  of  other  organs  which  is  so  often  found.  Pain  is  to 
be  expected  at  some  stage  in  the  disease,  but  like  tenderness,  it  is  inter- 
mittent and  often  mild.  Bladder  symptoms  and  a  pathological  urine 
are  found  in  a  considerable  number.  Scrotal  fistuhe  are  seen  in  over 
three-fourths  of  the  cases,  while  the  testicle  proper  is  invaded  in  about 
66  per  cent. 

While  the  sexual  desire  and  potency  seem  rarely  to  be  impaired,  even 
after  double  orchidectomy,  azoospermia,  due  to  occlusion  of  some 
portion  of  the  genital  duct,  is  found  in  a  very  large  percentage. 

The  diagnosis  of  a  typical  case  of  tuberculosis  of  the  epididymis  is 
easy.  Differential  diagnosis  may  be  extremely  difficult,  and  some- 
times can  be  settled  only  by  exploratory  incision. 

The  prognosis  is,  on  the  whole,  unfavorable.  In  our  own  cases  there 
has  been  an  operative  mortality  of  2.66  per  cent.,  comprising  4  deaths, 
all  of  general  miliary  tuberculosis.  Over  27  per  cent,  of  1 13  cases,  traced 
from  one  to  twenty-five  years  after  operation,  have  died  of  some  form  of 
tuberculosis.  My  experience  shows  that  until  at  least  ten  years  have 
elapsed  after  operation,  no  patient  can  be  said  to  be  cured  of  genital 
tuberculosis. 

If  the  technic  of  epididymovasectomy,  now  employed  by  us  at  the 
Massachusetts  General  Hospital,  is  done,  and  if  it  is  performed,  not 
under  ether,  but  with  novocain,  local  anesthesia  or  with  gas-oxygen, 
operative  mortality,  postoperative  sinuses  in  groin  and  scrotum,  and 
the  necessity  of  secondary  orchidectomy  will  be  practically  eliminated. 

Treatment  should  consist  of  conservative  surgery,  combined  with 
hygiene  and  tuberculin.  The  epididymis  and  accessible  portion  of  the 
vas  should  be  excised,  together  with  the  tunica  vaginalis  and  other 
tuberculous  tissues  in  the  scrotum.  The  testicle  may  be  freely  explored, 
and,  if  tuberculous,  the  diseased  portions  may  be  removed  by  currette  or 
knife.  Orchidectomy  is  rarely  necessary. 

Incidence  of  Tuberculosis. — The  statistics  of  the  world  show  tubercu- 
losis to  be  one  of  the  most  common  and  fatal  of  all  diseases.  Cornet26 
says  that  in  1894  in  Germany  the  death-rate  from  tuberculosis  was  25 


500  GENITAL   TUBERCULOSIS 

per  10,000,  while  in  1908  the  number  fell  to  16.24.  From  1896  to  1900, 
108,664  died  of  tuberculosis  of  the  lungs,  while  in  10,000  this  disease 
was  found  in  other  organs. 

From  1900  to  1909  the  deaths  in  the  registration  area  of  the  United 
States  were  159.4  per  100,000  from  lung  tuberculosis  alone,  and  182.6 
per  100,000  from  tuberculosis  of  all  organs.  In  Massachusetts,  for  1912, 
the  deaths  from  lung  tuberculosis  alone  were  131  per  100,000,  and  in 
Boston,  for  1913,  144.7  per  100,000.  Unfortunately,  there  seem  to  be 
no  available  national,  State  or  municipal  statistics  which  give  satisfac- 
tory details  of  the  distribution  of  the  disease  among  the  different  organs 
and  tissues. 

Incidence  of  Genito-urinary  Tuberculosis. — Hesse26  has  collected  a  large 
mass  of  statistics  on  the  frequency  of  urogenital  tuberculosis.  In 
10,864  autopsies,  lesions  of  the  genito-urinary  tract  were  found  in  2.13 
per  cent.  Krzywicki/0  in  500  autopsies  on  tuberculous  subjects,  found 
5  per  cent,  with  involvement  of  the  urogenital  tract.  Fowler  and 
Godlee72  found  5.27  per  cent.,  and  Reclus,52  many  years  before,  reported 
12.8  per  cent. 

Quite  startling  is  the  statement  of  Uchimura,67  that  in  1830  autopsies 
on  Japanese  subjects,  he  found  629  cases  of  tuberculosis,  the  urinary  or 
genital  tract  being  involved  in  210,  or  33  per  cent. 

The  above  figures  apply  largely,  if  not  entirely,  to  adults.  In 
children  the  urogenital  system  is  far  less  frequently  attacked. 

Ritter,26  in  19H9,  found  but  14  cases  among  5000  tuberculous  children; 
Molliere  and  Augagneur,68  1  instance  in  183  cases  of  lung  tuberculosis. 
The  figures  from  other  sources  give  a  proportion  of  urogenital  tubercu- 
losis in  infants  and  children  of  about  1  in  200  cases  of  general  tuber- 
culosis. 

Tuberculosis  of  the  Genital  Organs. — The  compilation  of  statistics  is 
made  a  little  difficult  for  the  reason  that  the  terms  "  genito-urinary" 
and  "urogenital"  tuberculosis  are  loosely  used  by  almost  all  writers, 
and  the  general  profession  is  only  too  apt  to  class  under  one  of  these 
names,  an  infection  of  the  genital  tract  alone.  While  both  the  genital 
and  urinary  organs  may  be  involved,  careful  inquiry  will  show  infection 
of  the  one  tract  to  be  secondary  to  that  of  the  other.  While  opinion  is 
practically  unanimous  that  the  kidney  is  the  first  organ  to  be  attacked 
in  infections  of  the  urinary  system,  there  is  less  unanimity  in  the  matter 
of  the  genital  system.  Most  authorities  now  agree  that  the  primary 
focus  is  in  the  epididymis,  but  certain  others  still  believe  that  the  in- 
fection begins  in  the  prostate. 

In  an  analysis  of  154  cases  of  epididymal  tuberculosis  from  the  Massa- 
chusetts General  Hospital,  the  writer5  found  tuberculosis  of  the  kidney 
in  18.  Of  these,  the  genital  lesion  preceded  the  renal  infection  in  11, 
whereas  in  7  the  kidney  was  first  involved. 

Keyes33  has  reported  100  patients  bearing  153  tuberculous  epi- 
didymes.  Among  these  renal  tuberculosis  had  preceded  the  genital 
lesion  in  1 1  cases,  while  extension  of  genital  tuberculosis  to  the  kidney 
took  place  9  times. 


TUBERCULOSIS  OF  THE  GENITAL  ORGANS  501 

From  our  material  and  from  the  literature,  I  have  gathered  1862 
cases  of  genito-urinary  tuberculosis.  Most  of  them  are  infections  of 
the  genital  tract  alone,  in  others  the  urinary  organs  are  also  involved. 
Certain  valuable  deductions  can  be  made  from  so  large  a  mass  of 
material. 

Out  of  821  cases  in  which  the  condition  of  the  epididymis  was 
described,  617,  or  75.1  per  cent.,  were  tuberculous. 

The  prostate  and  vesicles  together  were  said  to  show  tuberculosis  in 
1169  out  of  1675,  or  69.7  per  cent.,  while  disease  of  the  testicle  was  noted 
in  57.6  per  cent,  of  739  cases. 

It  is  therefore  quite  evident  that  next  to  the  epididymis,  the  prostate 
and  vesicles  are  most  frequently  attacked,  a  conclusion  borne  out  by 
still  further  data.  Hesse's26  statistics  comprise  815  cases  of  urogenital 
tuberculosis  collected  from  17  different  authors.  The  prostate  was 
tuberculous  in  559,  or  68.5  per  cent.  According  to  Burckhardt,25  the 
prostate  is  invaded  in  73  per  cent,  of  all  cases  of  genito-urinary  tuber- 
culosis, a  statement  based  upon  the  investigation  of  much  material.  As 
the  only  clinical  method  of  detecting  foci  in  the  prostate  is  by  digital 
examination,  there  is  a  certain  percentage  of  error,  an  observation  which 
I  find  agrees  with  that  of  Halle  and  Motz.25  This  error  lies  generally  in 
the  detection  of  small,  early,  and  centrally  located  lesions. 

Certain  authors  claim  to  have  found  isolated  prostatic  lesions  in 
considerable  number.  Out  of  a  possible  642  cases  I  find  that  the  pros- 
tate alone  was  regarded  as  tuberculous  in  21.6  per  cent  On  the  other 
hand,  Saxtorph,58  in  a  series  of  205  cases  of  genito-urinary  tuberculosis, 
has  reported  only  9  such  lesions,  and  Sawamura,56  from  various  sources, 
collected  but  1 1  more.  After  considering  all  the  evidence,  and  with  a 
large  clinical  and  laboratory  experience  of  his  own,  he  thinks  that  the 
primary  focus  of  genital  tuberculosis  may  arise  in  the  prostate,  an 
opinion  shared  by  K.  M.  Walker.71 

On  the  other  hand,  in  1911  George  Walker,70  whose  opinion  is  backed 
by  much  experimental  work,  has  laid  much  stress  on  the  rarity  of  pri- 
mary prostatic  tuberculosis,  and  after  reviewing  the  literature  with  great 
care,  found  only  3  cases  in  which  the  primary  focus  undoubtedly  lay  in 
the  prostate.  One  was  reported  by  Crandon,17  and  2  others  by 
Krzywicki.40  Practically  all  the  other  authors  mentioned  above,  who 
claim  to  have  found  isolated  prostatic  tuberculosis,  have  based  their 
conclusions  either  on  clinical  evidence,  or  upon  the  fact  that  although 
other  foci  were  present  in  the  genital  tract,  those  of  the  prostate  were 
further  advanced  and  more  extensive.  I  have  already  pointed  out  that 
clinical  evidence  is  unreliable,  and  the  consensus  of  opinion  of  experi- 
enced pathologists  is  that  the  apparent  age  of  a  tuberculous  process 
does  not  necessarily  determine  its  priority.  I  do  not  recall  a  single 
proved  case  in  the  course  of  ten  years  in  the  genito-urinary  clinic  at  the 
Massachusetts  General  Hospital,  nor  am  I  aware  that  the  autopsy 
records  of  the  hospital  contain  one. 

We  have  seen  that  the  seminal  vesicle,  like  the  prostate,  is  invaded 
secondarily  by  tuberculosis  with  great  frequency.  Primary  lesions,  on 


502  GENITAL  TUBERCULOSIS 

the  other  hand,  are  apparently  almost  as  rare  as  those  of  the  prostate. 
This  view  is  somewhat  shaken  by  the  fact  that  in  28.5  per  cent,  of 
287  cases,  of  the  series  of  1862  mentioned  above,  the  seminal  vesicle 
alone  was  said  to  be  tuberculous.  But  what  was  said  of  the  so-called 
isolated  prostatic  lesions,  applies  to  those  of  the  vesicles,  and  careful 
scrutiny  would  undoubtedly  eliminate  most  of  the  reported  cases. 

Guisy23  found  only  1  instance  in  86  cases  of  genito-urinary  tuber- 
culosis, while  Saxtorph58  discovered  but  2  examples.  Dreyer20  has 
found  2  specimens  at  autopsy  in  which  the  only  tuberculosis  of  the 
genital  tract  was  in  the  vesicles.  Teutschlander64  cites  another 
example. 

Primary  tuberculosis  of  the  testicle  is  conspicuous  for  its  rarity. 
K.  M.  Walker  and  Hawes72  accept  as  authentic  cases  reported  by 
Dufour,72  Langlet72  and  Schmidt,72  while  that  of  Barling,70  72  is  vouched 
for  by  these  authors,  as  well  as  by  George  Walker.72 

Tuberculosis  of  the  glans  penis  may  rarely  occur:  (1)  as  an  isolated 
lesion,  (2)  in  association  with  tuberculosis  of  the  genito-urinary  tract  or 
elsewhere,  (3)  by  direct  infection  (circumcision,  coitus).  George 
Walker70  has  collected  5  cases  in  the  first  group,  3  in  the  second  group, 
and  says  "  several  (instances  of  infection  from  circumcision)  have  been 
noted  in  the  Johns  Hopkins  Hospital."  He  has  collected  some  31 
others  from  other  sources.  I  have  not  seen  an  example  of  it. 

The  question  of  infection  from  coitus  has  raised  extensive  discussion. 
Pinaud31  cites  4  cases  of  tuberculosis  of  the  penis  from  fellatio.  Frank51 
and  Kraemer51  regard  tuberculosis  of  the  penis  from  normal  coitus  as 
impossible;  on  the  other  hand,  Senn,51  Oberndorfer51  and  Williams51 
regard  such  an  infection  as  possible. 

Although  there  seems  to  be  no  authentic  case  of  primary  urethral 
tuberculosis,  a  secondary  infection  is  seen  occasionally  in  the  course 
of  tuberculosis  of  the  genito-urinary  tract.  I  have  operated  upon 
such  a  case,  and  there  have  been  two  others  in  the  genito-urinary 
clinic  at  the  Massachusetts  General  Hospital  during  the  past  year. 
Asch,1  Sawamura,56  Uchimura,67  Halle  and  Motz25  and  others  report 
several  instances.  Such  strictures  often  accompany  bilateral  renal 
tuberculosis. 

Tuberculosis  of  the  vas  deferens  is  found  sooner  or  later  in  practically 
all  epididymal  lesions,  especially  on  the  side  first  involved.  Infections 
of  the  second  vas  are  not  so  common  and  develop  later  in  the  disease. 

Tubercle  bacilli  have  been  found  in  human  semen,  and  in  that  of 
animals,  by  numerous  observers.  In  some  cases  there  was  tubercu- 
losis of  the  urogenital  tract,  in  others  tuberculosis  of  the  lungs,  but 
healthy  genitalia.  George  Walker,70  after  a  careful  review  of  all  the 
literature  of  this  subject,  thinks  that  while  tubercle  bacilli  may  well  find 
their  way  into  the  semen  in  the  event  of  tuberculous  genitalia,  there  is 
no  positive  proof  that  they  can  be  secreted  by  healthy  organs.  The 
subject  is  of  some  importance,  as  undoubted  examples  of  vaginal  and 
cervical  tuberculosis,  arising  apparently  from  sexual  contact,  have  been 
reported. 


PATHOGEN  ESI  S  503 

Tuberculosis  of  Other  Organs. — The  frequency  of  a  tuberculous 
infection  of  other  organs,  preceding  or  accompanying  that  of  the 
genital  tract,  is  well  recognized. 

In  my  series  of  154  cases  of  tuberculosis  of  the  epididymis,  tuber- 
culosis of  organs  other  than  those  of  the  genito-urinary  tract  was  found 
in  55.8  per  cent.  The  lung  was  most  frequently  diseased,  with  a  total 
of  35  cases,  22.7  per  cent,  of  the  whole.  Kidney  and  bone  infections 
came  next,  with  7  cases  each.  I  have  also  shown  elsewhere3  that  the 
disease,  quiescent  or  active,  may  be  found  in  the  joints,  larynx,  glands, 
meninges,  middle  ear,  peritoneum  and  ischiorectal  fossa.  It  will  be 
found  in  many  cases  that  these  lesions  have  preceded,  often  for  several 
years,  the  tuberculosis  of  the  urogenital  tract. 

Keyes33  found  a  previously  existing  process  in  36  out  of  100  cases;  as 
he  gracefully  puts  it,  the  disease  is  always  "flitting  between  bone  and 
lung  and  urinary  tract."  Simmonds26  in  35  cases  of  genito-urinary 
tuberculosis  found  lung  infection  in  27,  Steinthal26  in  24  cases  found  the 
lungs  involved  22  times,  and  Socin26  42  times  in  52  cases  of  genito- 
urinary tuberculosis.  In  37  cases  of  the  latter,  Oppenheim26  found  81 
per  cent,  of  lung  involvement,  while  in  Reclus'52  cases  it  was  present  in 
66  per  cent. 

The  percentage  of  tuberculous  lesions  outside  the  genital  tract  is 
therefore  very  high,  and  a  lung  process  which  has  escaped  the  memory 
of  the  patient  and  the  observation  of  the  surgeon  may  not  infrequently 
be  uncovered  by  the  unwise  choice  of  ether  as  an  anesthetic. 

Pathogenesis. — The  question  as  to  how  the  tubercle  bacillus  reaches 
the  primary  focus  in  the  genital  tract  is  not  yet  definitely  settled ;  still 
more  in  doubt  is  the  path  taken  by  the  disease  to  its  secondary  foci. 

I  have  shown  that  the  relationship  between  genital  tuberculosis  and 
that  of  other  organs,  especially  the  lung,  is  very  close,  but  there  are 
occasional  exceptions  to  this  rule. 

Baumgarten,9  v.  Bruns,69  Kocher,34  v.  Braman,2  Durante2  and  Ziegler2 
have  reported  cases  in  which  tuberculosis  of  the  testis  and  epididymis 
was  the  only  demonstrable  focus  in  the  body,  while  Kowalewsky37  and 
Kraenzle37  have  found  isolated,  primary  tuberculosis  of  the  testicle 
(epididymis  ?)  in  bullocks.  These  are  the  only  instances  I  have  found 
of  isolated  genital  tuberculosis. 

I  have  no  doubt  that  in  the  majority  of  cases  the  disease  reaches  its 
primary  focus  in  the  genital  tract  by  way  of  the  blood  stream.  Its 
attack  upon  the  epididymis,  the  testicle  or  the  seminal  vesicle  may  be 
accounted  for  by  the  supposition  that  these  organs  have  an  excretory 
function,  and  that  the  disease  gains  a  foothold  upon  a  given  organ  at 
one  time  and  not  at  another,  because  of  either  an  overdose  of  the 
bacilli,  or  of  a  lowered  resistance  on  the  part  of  the  gland  involved. 

From  an  embryological  stand-point,  the  testicle  and  the  kidney  are 
much  alike,  and  there  is  ample  proof  that  the  latter  may  allow  the 
passage  of  tubercle  bacilli  and  other  organisms  without  injury  to  itself. 

The  filtration  of  bacteria  through  an  apparently  healthy  kidney  has 
been  demonstrated  by  many  observers,  among  them,  Meyer,47  Heyn,72 


504  GENITAL   TUBERCULOSIS 

Kraemer,39  Buday,14  Wyssokowicz74  and  Roily.53  More  recently 
Brown13  has  collected  many  instances  of  lung  tuberculosis,  some  in  his 
own  practice,  where  tubercle  bacilli  were  found  in  the  normal  urine,  and 
where,  later,  the  kidneys  were  shown  to  be  free  from  disease. 

Belfield11  has  shown  that  the  testicle  and  epididymis  are  excretory 
organs.  He  says,  "  While  the  kidney  is  provided  with  a  new  and  private 
sewer,  the  ureter,  the  testis  continues  to  use  the  frog's  old  urinary  duct, 
now  called  epididymis  and  vas  deferens.  This  excretory  function  of  the 
testicle  and  its  duct  illumines  both  its  intimate  alliance  with  the  kidney 
and  its  frequent  infection  from  the  blood."  The  writer6  has  already 
shown  in  a  study  of  infections  of  the  testicle,  that  in  certain  cases  the 
presence  of  organisms  in  both  testicle  and  epididymis  could  be  accounted 
for  in  no  other  way  than  by  assuming  that  these  organs  had  an 
excretory  function. 

There  seems  to  be  also  considerable  evidence  that  the  seminal  vesicle 
can  assume  an  excretory  role,  not  only  for  tubercle  bacilli,  but  for  other 
organisms  as  well. 

Huet's2S  experimental  work  has  shown  not  only  that  bacteria  are 
present  in  the  secretion  of  the  seminal  vesicles  of  healthy  animals, 
but  also  that  in  animals  dying  of  acute  sepsis  the  specific  organism  may 
be  found  in  this  secretion.  The  seminal  vesicle  may  thus  be  looked 
upon  not  only  as  a  reservoir  for  spermatozoa,  and  a  secretory  organ, 
but  also  as  an  excretory  organ.  Hueter,29  Simmonds2  and  Spano61 
share  this  view. 

There  seems  to  be  some  evidence  that  the  prostate  also  plays  the  part 
of  an  excretory  organ.  Jani  and  Xakarai/"5  in  188(5  and  1898  respec- 
tively, found  tubercle  bacilli  in  the  normal  prostate  of  patients  dying 
of  lung  tubercuL 

I  have  seen  a  number  of  cases  of  acute  infection  of  the  prostate  with 
the  B.  coli,  there  being  no  demonstrable  focus  of  infection  either  in  the 
kidneys,  the  bladder,  or  the  external  genitals.  I  have  regarded  this 
infection  as  hematogenous,  but  whether  it  is  to  be  regarded  as  an 
excretory  effort  on  the  part  of  the  prostate  I  am  unable  to  say. 

Admitting  that  the  epididymis  is  the  primary  focus,  is  the  subse- 
quent prostatic  infection  of  hematogenous,  deferential,  or  lymphatic 
origin? 

While  the  tubercle  bacillus  may,  in  certain  cases,  be  carried  from 
epididymis  to  prostate  by  the  blood  stream,  it  is  more  likely  that  the 
more  direct  route  offered  by  the  vas  deferens,  or  by  the  lymphatics  is 
responsible. 

At  first  sight  it  would  appear  that  the  spread  of  the  disease  through 
the  vas  in  the  direction  of  the  seminal  stream,  the  descending,  or,  as 
some  miscall  it,  the  ascending  route,  offered  an  easy  explanation  for  the 
early  and  frequent  prostatic  involvement.  While  this  view  has  many 
proponents,  it  is  strongly  assailed  by  numerous  competent  observers. 
Baumgarten*  and  his  pupils,  especially  Kraemer ,3S  have  been  the  chief 
proponents  of  the  descension  theory,  this  opinion  being  based  on  much 
experimental  and  clinical  observation.  Among  others  who  hold  this 


PATHOGEM  505 

view  are  Tylinski,66  Cholzoflf,16  Su<rimura/-  Sangionri,1™  Sawamura^  and 
Gotzl." 

While  K.  M.  Walker71  regards  genital  tuberculosis  as  primary  in  the 
prostate,  certain  of  his  observations,  both  experimental  and  clinical, 
show  that  a  flow  of  infected  secretions  through  the  lumen  of  the  vas 
from  the  diseased  epididymis  may  occur.  This  sets  up  a  tuberculous 
process  in  the  vas,  most  marked  at  its  epididymal  extremity,  gradually 
shading  off  to  normal  tissue  (unless  the  disease  is  of  long  standing' 
toward  the  external  inguinal  ring.  My  own  observations  and  those  of 
others  have  repeatedly  borne  out  the  truth  of  this  observation.  The 
only  question  is  whether  the  advance  of  the  disease  has  been  intra- 
canilicular  or  intramural. 

Although  in  certain  instances,  the  advance  of  the  tubercle  bacillus 
through  the  vas  is  possible,  no  positive  proof  can  be  shown,  and  the 
opponents  seem  to  have  the  best  of  the  argument.  The  fact  that 
tuberculosis  of  the  vas  often  obliterates  it>  lumen  near  the  epididymis 
before  the  upper  part  is  involved,  thus  stopping  the  stream  of  secretion, 
at  once  places  the  proponents  in  an  awkward  position.  Furthermore, 
how  are  they  to  account  for  the  fact  that  even  if  the  vas  is  ligated,  the 
advance  of  the  disease  from  epididymis  to  prostate  may  be  delayed, 
but  not  stopped  ?  This  phenomenon  has  been  observed  in  a  number  of 
animals  by  George  Walker.70  How  also,  are  they  to  explain  my  observa- 
tions and  those  of  Balliano,-  that  the  epididymis,  prostate  and  vesicles 
may  be  tuberculous  and  the  intervening  vas  perfectly  normal? 

These  observations  can  be  explained  only  by  discarding  the  idea  that 
the  disease  spreads  through  the  lumen  of  the  vas.  except  in  certain 
instances,  and  by  adopting  the  view  that  the  lymphatics  of  the  vas  itself 
are  to  be  held  accountable  for  the  spread  of  the  disease  in  most  cases, 
for,  according  to  Testut,63  the  lymphatics  of  the  vas  are  very  rich  and 
voluminous,  extending  throughout  its  course. 

This  hypothesis  explains  the  phenomena  just  cited,  as  for  example, 
the  invasion  of  the  prostate  by  tuberculosis  in  the  presence  of  a  normal 
or  of  a  ligated  vas.  The  possibility  of  this  is  explained  by  K.  M. 
Walker71  who  says:  "The  bacillus  of  tubercle  does  not  always  indicate 
its  presence  in  the  tissue  by  the  production  of  a  tuberculous  lesion." 

"Structures  may  be  shown  under  the  microscope  to  be  absolutely 
free  from  signs  of  tuberculosis,  and  yet,  nevertheless,  have  furnished 
the  path  along  which  the  tuberculous  invasion  has  progressed." 

In  certain  cases  of  long  duration,  the  whole  spermatic  cord  may  be 
involved,  so  that  attempts  to  separate  the  vas  from  it  may  be  either 
difficult,  where  there  are  dense  adhesions,  or  impossible,  where  all  the 
structures  are  imbedded  in  dense  connective  tissue.  But  in  many 
early  cases,  one  may  find  an  involvement  of  the  prostate  and  vesicles  in 
the  presence  of  a  normal  or  but  slightly  affected  spermatic  cord. 

Although  every  argument  presented  here,  for  and  against  the  vas  and 
its  lymphatic's  can  be  refuted,  I  think  the  evidence  at  hand  favors  the 
lymphatic  transmission  of  tuberculosis  from  epididymis  to  prostate.  I 
think  the  stream  of  secretions  in  the  vas  deferens  is  too  scanty  and  slug- 


506  GENITAL  TUBERCULOSIS 

gish  to  be  a  factor  in  the  passage  of  bacilli.  In  such  an  event,  with 
organisms  in  contact  with  the  entire  length  of  the  vas,  we  should  find 
one  end  quite  as  much  involved  as  the  other.  But  such  is  not  the  case. 
The  epididymal  extremity  is  first  and  most  seriously  invaded,  the  patho- 
logical changes  usually  disappearing  entirely  as  the  inguinal  canal  is 
approached.  To  my  mind  this  phenomenon  is  an  evidence  that  the 
disease  travels  by  way  of  the  lymphatics. 

I  have  already  pointed  out  that  tuberculosis  of  one  epididymis  is 
followed  sooner  or  later  by  an  involvement  of  its  fellow  in  a  large  per 
centage  of  cases.  I  have  been  unable  to  settle  the  question  as  to  the 
manner  of  invasion  of  the  second  side  in  spite  of  much  clinical  observa- 
tion, nor  do  I  find  that  the  extensive  experimental  work  of  others  throws 
much  light  on  the  matter.  The  paths  of  communication — vascular, 
deferential  and  lymphatic — are  the  same  as  before,  but  the  infection  is 
now  undoubtedly  influenced  by  the  presence  of  an  already  tuberculous 
prostate  and  seminal  vesicle. 

Many  (Simmonds,  Bungner,  Kraemer,  Bruns,  Friedlander,  Volk- 
mann,  Jordan  and  Zamurawkin,  all  quoted  by  Tylinski66)  believe  that 
the  infection  of  the  second  side,  like  that  of  the  first,  is  hematogenous. 
Cholzoff16  also  inclines  to  this  view.  The  possibility  of  it  cannot  be 
denied. 

While  the  ability  of  the  tubercle  bacillus  to  pass  through  the  vas  in 
the  direction  of  its  current  has  been  shown  to  be  doubtful,  the  chances  of 
its  proceeding  against  the  current  must  be  even  less.  Yet  I  find  that 
Ziegler,2  Teutschliinder,64  Kuhn,41  and  Kocher35  consider  this  possible 
not  only  for  the  tubercle  bacillus  but  also  for  the  gonococcus  and  other 
non-motile  organisms.  A  few  of  George  Walker's70  experimental  results 
with  tuberculosis  and  a  few  clinical  cases  cited  by  him  seem  to  bear  out 
this  view.  If  the  passage  of  these  organisms  through  the  vas  from 
urethra  to  epididymis  does  occur  it  can  be  accounted  for  only  by  a  re- 
versal of  the  normal  peristalsis  of  that  structure,  a  phenomenon  care- 
fully studied  by  Oppenheim  and  Low.49  It  was  observed  in  rabbits 
and  guinea-pigs  and  in  one  or  two  humans,  but  did  not  occur  in 
dogs.  It  was  produced  by  stimulation  of  the  hypogastric  nerve  or  by 
irritation  of  the  verumontanum.  Its  experimental  production  is  evi- 
dently not  constant;  clinically,  it  is  certainly  rare. 

Epididymitis  of  gonococcal  or  pyogenic  origin  is  occasionally  seen, 
when  the  sudden  onset,  a  few  hours  after  some  otherwise  trivial  injury 
(such  as  the  passage  of  a  sound)  cannot  well  be  accounted  for  in  any 
other  way.  I  have  never  seen  a  tuberculous  epididymitis  begin  thus, 
perhaps  because  the  organism  develops  so  slowly.  Moreover,  if  a 
tuberculous  process  can,  as  has  been  shown,  obliterate  the  epididymal 
end  of  the  first  vas,  it  can,  by  the  same  token,  occlude  the  urethral  end 
of  the  second  vas  by  tuberculosis  spreading  from  prostate  or  vesicles. 
Proof  of  this  is  offered  by  my  observations3  4  and  those  of  Keyes33  that 
a  very  large  proportion  of  men  with  tuberculosis  of  even  one  epididymis 
have  azoospermia,  indicating  an  obstruction  of  the  genital  duct  on  both 
sides.  The  pathological  studies  of  K.  M.  Walker71  bear  out  this  belief. 


PATHOGENESIS  507 

I  should  like  to  think  with  Konig,36  Lancereaux,66  Schmidt,59  and 
Sawamura56  that  the  infection  of  the  second  epididymis  is  a  simple  case 
of  transmission  through  vas,  urethra,  and  vas,  but  the  evidence  against 
it  is  unimpeachable. 

Unless  one  takes  the  view,  as  I  am  strongly  inclined  to,  that  the 
infection  of  the  second  epididymis  occurs  through  the  blood  stream, 
possibly  as  an  excretory  phenomenon,  the  question  narrows  itself  down, 
as  in  the  case  of  the  first  epididymis,  to  the  lymphatics  as  being  the 
most  probable  bridge  between  prostate  and  epididymis.  It  is  true  that 
in  such  an  event  the  infection  must  travel  in  a  direction  contrary  to  that 
of  the  normal  lymph  stream,  but  Balliano2  has  shown  that  this  can 
take  place. 

The  following  case,  recently  seen  (September  15,  1915)  by  my  col- 
league, Dr.  Hugh  Cabot,  furnishes  apparently,  substantial  proof  of  the 
soundness  of  this  theory: 

A  man,  aged  nineteen  years,  noticed  a  swelling  of  the  right  side  of  the 
scrotum  about  two  years  ago.  In  May,  1915,  the  right  testicle  was 
removed  by  another  surgeon  for  tuberculosis,  the  vas  being  divided  at  a 
point  opposite  the  external  ring.  About  two  weeks  ago  the  left  side  of 
the  scrotum  became  swollen  and  tender. 

Examination  showed  the  right  testicle  missing.  A  sinus  led  to  the 
stump  of  the  vas,  which  was  surrounded  by  a  mass  of  indurated  tissue. 
On  the  left  side  the  testicle  and  epididymis  seemed  normal,  but  at  the 
top  of  the  scrotum,  close  to  the  vas  and  evidently  connected  with  it, 
there  was  a  hard,  nodular  mass  the  size  of  an  English  walnut.  The 
urine  was  clear,  but  contained  a  few  shreds. 

Operation  October  11,1915.  Left  epididymis  and  testicle  apparently 
perfectly  normal.  The  lower  end  of  the  vas  near  the  epididymis  not 
thickened.  Near  the  top  of  the  scrotum  there  was  an  indurated  mass, 
adherent  to  the  vas  and  spermatic  cord  as  well  as  to  the  overlying  skin. 
This  was  excised,  together  with  the  epididymis  and  vas,  up  to  the  exter- 
nal inguinal  ring.  An  additional  length  of  vas  was  then  removed 
through  a  counter-incision  opposite  the  internal  inguinal  ring.  ,  The 
inguinal  portion  of  the  vas  showed  two  caseous  nodules,  one  of  which 
was  removed.  The  vas  was  torn  off  (accidentally)  at  the  second  (distal) 
nodule,  which  could  not  be  reached  over  the  pelvic  brim. 

The  inguinal  canal  on  the  right  side  was  then  opened.  The  vas  was 
isolated,  drawn  up  over  the  pelvic  brim,  ligated  and  divided,  thus 
removing  the  inguinal  portion,  together  with  the  mass  of  inflammatory 
tissue  surrounding  its  stump. 

The  tissue  excised  from  both  sides  is  clearly  shown  in  the  accom- 
panying photograph  (Fig.  220) . 

Careful  microscopic  examination  of  the  left  epididymis  shows  no 
evidence  whatever  of  tuberculosis  or  other  inflammatory  change. 
Sections  of  the  left  vas  lying  between  the  epididymis  and  the  large 
tuberculous  mass  (Fig.  213)  are  likewise  normal.  Beyond  this  point 
the  vas  shows  various  tuberculous  changes. 

The  excised  portion  of  the  right  vas  also  showed  tuberculous  changes. 


508 


<;  /:.\ 7  TAL  T  UBERC  ULOSIS 


Fortunately  for  our  purposes  the  patient  was  seen  when  the  advance 
of  the  disease  upon  the  second  side  was  in  its  initial  stages  and  before 
the  epididymis  was  involved. 


FIG.  220. — A,  right  vas;  1,  proximal  end  with  surrounding  sinus;  2,  distal  end,  divided 
at  internal  inguinal  ring.  B,  left  epididymis,  upper  pole  1,  body  1',  lower  pole  1".  Mass 
of  tuberculous  tissue  at  upper  part  of  scrotum,  2;  caseous,  spindle-shaped  nodule,  3; 
lying  within  thickened  vas,  4- 

1  )elli  Santi19  injected  tubercle  bacilli  into  the  urethra,  and  after  three 
days  demonstrated  their  presence  in  the  testicle.  Paladino-Blandini50 
obtained  similar  results.  K.  M.  Walker  and  Hawes72  injected  B. 
prodigiosus,  Staph.  aureus,  and  other  organisms  into  the  urethra  of 
guinea-pigs.  Eight  to  ten  hours  later  they  obtained  cultures  of  these 
organisms  from  both  epididymes,  and  got  a  scanty  growth  from  the 


PATHOLOGY  509 

testicles  and  seminal  vesicles.  Especially  important  is  the  fact  that 
positive  cultures  were  obtained  from  the  lymphatics  of  the  vas  deferens. 
Tubercle  bacilli  have  also  been  demonstrated  in  the  peridifferential 
lymphatics  by  Cholzoff.16 

Furthermore,  it  has  been  shown  experimentally  by  Kappis32  and 
Baumgarten10  that  the  spread  of  tuberculosis  in  a  direction  opposite  to 
the  normal  stream  of  secretion  can  occur  only  if  that  stream  is  stopped. 
These  observations  coincide  with  the  fact  already  noted,  that  the  vasa 
deferentia  are  very  frequently  obstructed  on  both  sides  early  in  the 
disease. 

When  the  prostate,  testicle,  cr  seminal  vesicle  is  the  primary  seat  of 
genital  tuberculosis  there  is  no  reason  to  suppose  that  its  origin  is 
different  from  that  of  the  epididymal  process. 

In  the  event  of  renal  tuberculosis,  or  of  the  filtration  of  tubercle 
bacilli  through  the  healthy  kidney,  the  prostate  may  be  first  invaded, 
with  subsequent  epididymal  involvement,  or  the  epididymis  may  be 
directly  attacked.  In  either  event  the  tubercle  bacillus  doubtless 
follows  the  same  paths  to  the  first  epididymis  which  have  been  regarded 
as  probable  in  infections  of  the  second  side. 

Tuberculosis  of  the  testicle,  secondary  to  that  of  the  epididymis, 
may  arise  either  by  continuity,  by  spreading  against  the  seminal 
stream  through  the  epididymal  tubules  or  through  the  lymphatics. 
Here,  again,  the  latter  course  seems  to  be  the  most  likely,  but  actual 
proof  is  lacking.  Yet  it  is  significant  that  the  most  frequent  site  of 
secondary  testicular  involvement  is  the  body  of  Highmore  at  which 
point  the  lymphatics  of  the  testicle  concentrate  (Testut63) . 

Pathology. — The  microscopic  picture  presented  by  tuberculosis  of 
the  genital  organs  differs  little  from  that  seen  in  other  tissues.  Whereas 
elsewhere,  notably  in  the  lung,  a  tuberculous  focus  may  often  wall  itself 
off  and  heal  spontaneously,  the  tubercle  bacillus  seems  never  to  cease  its 
activity  once  it  enters  the  genito-urinary  tract.  In  certain  cases  it  may 
remain  quiescent  for  a  long  time  (especially  in  the  epididymis)  bursting 
forth  now  and  again  with  surprising  violence,  all  the  while  replacing  the 
normal  tissues  of  the  organ  by  a  process  of  caseation  and  cicatrization. 

It  has  been  my  observation  that  the  tuberculous  process  attacks  first 
the  lower  pole  or  tail  of  the  organ.  Cholzoff,16  K.  M.  Walker,71  and 
George  Walker70  report  a  similar  experience.  The  early  stages  of 
epididymal  tuberculosis  have  been  well  described  by  the  latter  in  his 
experimental  work.  He  says :  "  The  initial  lesion  begins  just  under  the 
epithelial  layer  of  the  tubules.  Soon  there  is  an  infiltration  of  the 
epithelium  by  small  round  cells,  a  few  epithelial  cells  and  leukocytes. 
This  process  progresses,  the  whole  lining  becomes  disintegrated,  and 
the  lumen  of  the  tubules  is  filled  \vith  exfoliated  and  adventitious  cells. 
These  soon  die  and  are  converted  into  tuberculous  debris.  The  con- 
nective tissue  framework  becomes  invaded  secondarily,  although  there 
is  an  almost  complete  destruction  of  the  epithelial  lining  before  the 
connective  tissue  wall  is  affected." 

The  relation  of  the  early  stages  of  the  tuberculous  foci  to  the  tubules 


510 


GENITAL  TUBERCULOSIS 


has  also  been  pointed  out  by  Cholzoff,16  but  Tylinski,66  in  tuberculous 
testicles  of  dogs,  showed  the  tubercles  to  be  in  the  interstitial  con- 
nective tissue,  especially  in  the  neighborhood  of  blood  effusions.  An 
examination  of  a  large  amount  of  the  material  from  our  clinic  has  shown, 
generally  speaking,  that  the  tuberculous  process  was  intertubular, 
involving  only  the  surrounding  connective  tissue  and  leaving  the 
tubules  intact.  In  many  sections  the  tubules  were  more  or  less  com- 
pressed by  the  encroaching  peritubular  process,  and  in  the  later  stages 
they  showed  evidence  of  complete  destruction.  The  tendency  of  the 
tuberculous  epididymis  to  form  abscesses  and  sinuses  is  generally 
recognized.  These  will  generally  be  found  at  the  lower  pole  of  the 
organ  (Fig.  221) ,  but  in  certain  extensively  d  iseased  epididymes,  purulent 
foci  and  even  sinuses  are  to  be  seen  at  the  upper  pole  as  well,  and  occa- 
sionally in  the  intervening  portion. 


FIG.  221. — Dissection  of  tuberculous  epididymis.  A,  testicle;  B,  upper  pole  of  epi- 
didymis; C,  body,  with  tuberculous  nodule;  D,  much  enlarged  lower  pole,  connected 
by  a  sinus  with  scrotal  skin  (E);  F,  nodular  and  thickened  lower  pole  of  vas;  G,  cut  end 
of  vas,  slightly  thickened.  (Specimen  from  Warren  Museum.) 


It  is  apparently  still  unsettled  whether  the  initial  tuberculous  process 
in  the  testicle  begins  in  the  canals  or  in  the  interstitial  tissue.  Many 
competent  observers,  Baumgarten,8 10 19  Cholzoff16  and  others  think  it 
always  commences  in  the  canals  or  in  their  neighborhood,  whereas 
Samuel,54  after  a  careful  pathological  study  of  human  testicles,  con- 
cluded that  the  disease  spread  by  way  of  the  interstitial  tissue.  George 
Walker's70  experimental  work  throws  light  on  this  question.  He  says: 


PATHOLOGY 


511 


"  In  those  cases  in  which  the  animals  had  received  injections  into  the 
aorta  and  had  been  killed  within  a  short  time  afterward,  I  found  in 
one  gland  several  small  capillaries  containing  tubercle  bacilli,  and  in 
another  I  observed  very  young  tubercles  close  to  the  bloodvessels.  It 
is  presumable  from  this  that  the  organisms  penetrate  the  walls  and 
form  a  tubercle  in  the  immediately  surrounding  tissues.  This  process 
may  occur  in  the  intracanalicular  connective  tissue  or  just  under  the 
epithelium.  As  the  process  advances,  the  tubercles  coalesce  and  form 
distinct  nodules." 


<J.    . 


FIG.  222. — Longitudinal  bisection  of  testicle  extensively  invaded  with  tuberculosis. 
The  disease  follows  roughly  the  fibrous  septa  of  the  organ.  The  bisected  upper  and  lower 
poles  of  the  epididymis  are  seen  above  and  below  in  the  median  line.  (Specimen  from 
Warren  Museum.) 

Balliano2  recognizes  two  forms  of  tuberculosis  affecting  the  testicle 
and  epididymis.  The  usual  type  is  that  which  settles  primarily  in  the 
epididymis,  with  the  formation  of  single  nodules.  This  soon  goes  on  to 
caseation,  abscesses  and  sinuses,  and  is  to  be  regarded  as  of  hematogen- 
ous  origin.  The  disease  arises  primarily  in  the  interstitial  tissue.  The 
second  type,  evidently  rare,  arises  through  the  natural  channels, 
urethra,  prostate,  and  vas.  It  generally  attacks  epididymis  and  tes- 
ticle simultaneously,  has  its  primary  seat  in  the  interior  of  the  seminal 
canals,  and  gives  rise  to  an  increase  of  interstitial  tissue  with  round-cell 
infiltration  and  general  increase  of  sexual  tissue.  It  somewhat  re- 


512 


GEMTAL   TUBERCULOSIS 


sembles  sarcoma.  In  advanced  states  there  is  caseation  and  destruc- 
tion of  the  organ.  But  if  the  resistance  of  the  individual  is  high  a 
clinical  cure  may  occur,  with  induration  of  the  organ  (orchitis  fibrosa) 
resembling  the  obliterated  and  scarred  tuberculous  foci  of  the  other 
organs  so  often  seen  at  autopsy. 

The  question  of  spermatogenesis  in  a  tuberculous  testicle  has  re- 
ceived much  attention.  It  may  persist  until  late  in  the  disease.  Orth54 
says  that  in  a  tuberculous  human  testicle,  of  which  the  centre  showed 
complete  caseation,  one  could  recognize  clearly  the  necrotic  walls  of  the 
tubules,  and  in  them,  in  the  midst  of  caseous  nodules,  one  could  see 
many  spermatozoa.  SimmondsH  has  seen  spermatozoa,  often  in  large 


FIG.  223. — Longitudinal  section  of  tes- 
tical  and  epididymis.  Tuberculosis  chiefly 
of  the  upper  pole  of  the  latter.  Large 
tuberculous  nodule  in  upper  pole  of  tes- 
ticle in  the  body  of  Highmore,  the  favorite 
seat  of  testicular  tuberculosis.  (Specimen 
from  Warren  Museum.) 


FIG.  224. — Longitudinal  section  of 
testicle  and  epididymis  showing 
compression  of  the  testicle  by  exten- 
sive tuberculous  involvement  of  the 
lower  pole  of  the  epididymis.  (Speci- 
men from  Warren  Museum.) 


numbers,  in  an  extensively  destroyed  testicle.  Baumgarten10  observed 
that  while  the  tubules  were  more  and  more  compressed  and  squeezed 
together  by  the  development  of  inflammatory  connective  tissue  and 
infiltration,  the  epithelium  itself  still  persisted  and  spermatogenesis  was 
carried  on  by  active  karyokinesis. 

The  macroscopic  appearances  of  the  testicle  when  removed  at  opera- 
tion may  show  an  organ  studded  with  miliary  tubercles  or  it  may 
present  a  caseous  or  necrotic  focus  near  its  junction  with  the  epididymis 
( Fig.  ±22).  All  observers  agree  that  the  testicular  invasion  generally 
begins  at  the  body  of  Highmore  (Fig.  223),  whence  it  spreads  to  other 
parts.  In  certain  cases,  even  with  a  long-standing  and  extensive 


PATHOLOGY  513 

tuberculosis  of  the  epididymis,  the  testicular  tissue  remains  intact  and 
will  he  found  compressed  by  the  slowly  enlarging  epididymis,  as  shown 
in  Fig.  224.  It  not  infrequently  happens  that  a  small  and  centrally 
located  tuberculous  process  in  the  testicle  will  give  no  external  sign  of 
its  presence.  For  this  reason  exploratory  orchidotomy  is  to  be  recom- 
mended in  doubtful  cases.  Yet  in  spite  of  careful  macroscopic  examina- 
tion our  experience  has  shown  that  60  per  cent,  of  the  testicles  as>oci- 
ated  with  tuberculous  epididymes  and  removed  showed  microscopic 
evidence  of  tuberculosis. 

Before  leaving  the  pathology  of  epididymis  and  testicle  it  may  be 
observed  that  an  actively  tuberculous  process  of  the  tunica  vaginalis 
is  occasionally  found.  The  serous  coat  is  deeply  injected,  there  are 
innumerable  tiny  ecchymoses,  and  small  tubercles  may  dot  its  surface 
or  that  of  the  epididymis.  In  practically  every  case  more  or  less 
hydrocele  fluid  escapes  when  the  sac  is  opened,  and  its  walls  are  adherent 
to  a  greater  or  less  extent,  especially  at  the  lower  pole. 

The  pathology  of  the  tuberculous  prostate  has  been  given  much  study. 
Experimental  infections  naturally  show  the  earliest  stages  better  than 
clinical  specimens,  especially  as  the  latter  are  seen  at  autopsy  when  the 
disease  is  well  advanced.  The  first  changes  begin  just  under  the  epithelial 
layer  of  the  ducts.  George  Walker70  says  of  the  subsequent  changes: 

"  After  the  formation  of  a  considerable  subepithelial  aggregation,  the 
epithelium  becomes  invaded  by  the  adventitious  cells  and  the  lumina 
of  the  ducts  are  encroached  upon ;  later  the  lumina  are  filled  with  a  mass 
of  cells  in  which  one  can  distinguish  a  large  number  of  epithelioid, 
degenerated  epithelial,  small  mononuclear  cells,  and  polymorphonuclear 
leukocytes.  Very  soon  after  this  stage,  or  in  fact  along  with  it,  one 
sees  a  number  of  degenerated  and  dead  cells;  the  nuclei  are  fragmented, 
and  the  protoplasm  is  granular  and  cloudy.  As  this  advances,  the  cells 
are  converted  into  a  granular  mass  without  any  definite  cellular  differ- 
entiation. In  the  ducts  the  epithelial  lining  disappears,  leaving  the 
walls  made  up  solely  of  connective  tissue.  The  prostate  is  converted 
into  a  number  of  cheesy,  rod-like  masses,  interspersed  among  which  is  the 
connective  and  muscular  tissue  of  the  gland.  This  later  breaks  down 
and  the  whole  gland  is  converted  into  tuberculous  tissue." 

Halle  and  Motz,25  with  a  large  experience  at  the  Necker  Hospital, 
divide  the  tuberculous  changes  of  the  prostate  into 

1.  Small,  primary  tubercles. 

2.  Large  tubercles,  which  may  present  macroscopically  a  stage  of 
softening,  a  stage  of  encystment,  and  a  stage  of  fibrous  induration. 

3.  Encysted  tuberculous  abscesses. 

4.  Tuberculous  cavities,  partly  or  wholly  open. 

5.  A  special  form  of  massive  infiltration,  caseous  or  necrotic. 

The  latter  type  seems  to  predominate.  Careful  pathological  study 
shows  that  the  tubercles  are  especially  abundant  in  the  middle  lobe, 
but  in  more  than  half  both  lobes  are  attacked.  Unilateral  lesions  are 
distributed  without  marked  predilection  for  one  or  the  other  side. 
According  to  Ileclus52  and  to  Simmonds,25  the  early  lesions  are  often 

M  u     i — 33 


514  GEMTAL    TUBERCI.'LOXIS 

unilateral  in  the  lobe  corresponding  to  the  diseased  epididymis. 
Anatomical  facts  do  not  clearly  confirm  this,  but  in  the  early  stages  it  is 
hard  to  confirm. 

( 'holzoff16  says  that  tuberculosis  of  the  prostate  occurs  in  the  form  of 
cheesy,  degenerated  tubercles  of  different  size  and  rarely  the  whole  organ 
shows  homogeneous,  cheesy  degeneration.  Involution  of  the  disease  he 
regards  as  rare. 

Gotzl22  thinks  the  tuberculous  prostate  rarely,  if  ever,  becomes 
encapsulated  and  calcified. 

Hesse26  classifies  the  changes  in  the  prostate  thus: 

1.  The  stage  of  tubercle  formation. 

2.  The  stage  of  confluence  of  tubercles. 

(a)  Caseation. 

(6)  Abscess  formation. 

3.  The  encroachment  upon 

(a)  The  periprostatic  tissues. 

(6)  The  whole  organism,  as  an  acute  miliary  tuberculosis. 

4.  The  stage  of  healing. 
Alburran1  recognized : 

1.  Nodular  infiltration. 

2.  The  cavernous  type. 

3.  The  degenerative  form. 

4.  Prostatitis  with  periprostatitis. 

Many  investigators,  Hesse,26  Lowenstein45  and  others,  recognize  a 
bacillary  catarrh  of  the  prostate  as  one  of  the  earliest  changes  of  tuber- 
culosis. Macroscopically,  there  is  nothing  to  be  seen,  and  even  the 
microscope  may  find  but  little  alteration.  The  prostatic  secretion, 
however,  is  loaded  with  virulent  tubercle  bacilli. 

Tuberculosis  of  the  Seminal  }'esicles. — For  a  good  description  of  the 
tuberculous  seminal  vesicles  we  are  again  indebted  to  George  Walker,70 
whose  experimental  investigations  have  been  most  thorough.  The 
earliest  specimen  he  found  was  five  days  after  inoculation.  There  is 
at  first  a  diffuse  injection  of  the  mucosa  with  a  few  pin-point  tubercles. 
These  gradually  enlarge  to  pin-head  size  in  about  twelve  days.  They 
fuse  and  finally  cover  the  whole  mucosa,  on  which  there  are  tiny 
ulcers.  Later,  there  appears  an  exudate  of  a  tough,  fibrous,  necrotic 
mass.  This  replaces  the  mucosa,  and  fills  the  lumen  with  semisolid 
grayish-yellow  material.  The  walls  become  invaded  and  much  thick- 
ened, and  composed  almost  entirely  of  tuberculous  tissue.  In  the 
advanced  stages  there  is  an  extensive,  adhesive,  perivesicular  tuber- 
culous process.  In  a  few  vesicles  there  were  discrete,  fair-sized 
tubercles  here  and  there,  with  almost  normal  mucosa  between. 

Microscopically  the  disease  is  seen  to  begin  just  under  the  epithelium. 
There  is  a  small  aggregation  of  epithelioid  cells  together  with  a  few 
small,  round  cells;  leukocytes  are  added  to  these  and  there  is  finally 
formed  a  small  olive-shaped  mass  of  cells  which  raise  the  epithelium, 
and  shortly  invade  it.  Sometimes  there  is  an  early  invasion  of  the 
epithelium  from  the  tissues  below,  and  the  tubercles  appear  to  be  formed 


PATHOLOGY  515 

in  the  epithelial  layer.  In  other  cases  the  tuberculous  process  pushes 
directly  upward,  invading  the  epithelial  structures  and  protruding 
above  the  .surface;  there  is  no  epithelial  cap,  and  the  whole  of  the 
minute  papule  is  composed  of  tuberculous  tissue.  As  the  tuberculous 
process  invades  the  epithelial  layer,  a  break  occurs  in  the  surface  and 
an  ulcer  is  formed.  This  gives  rise  to  fibrinous  yellowish  exudate  which 
often  covers  the  whole  surface  with  a  thick,  diphtheroid  membrane. 
The  whole  epithelium  disappears  and  the  membrane  rests  directly  on 
the  submucous  tissues.  In  advanced  cases  the  walls  are  thickened 
with  caseous  infiltration,  and  widespread  destruction  of  muscle  and 
fibrous  tissue  occurs.  The  process  extends  to  the  outside  and  in- 
volves the  fascial  covering. 

This  invasion  of  the  perivesicular  and  of  the  periprostatic  tissues  is 
especially  important.  As  I  shall  point  out  later,  it  not  only  makes  the 
removal  of  these  organs  difficult,  or  impossible,  but  it  also  makes  the 
complete  ablation  of  the  disease  a  futile  effort.  As  seen  at  operation 
or  autopsy,  the  entire  vesicle  is  generally  found  to  be  invaded  by  the 
disease,  and  in  most  cases  both  organs  are  involved. 

Although  many  authors  do  not  recognize  the  possibility  of  the  sub- 
sidence of  a  tuberculous  infection  of  the  prostate  and  vesicles,  such  an 
event  frequently  takes  place.  My  observations  extending  over  a  num- 
ber of  years  show  a  marked  cessation  in  the  activity  of  the  infection  of 
these  organs  (amounting  to  a  clinical  cure)  after  removal  of  the  epi- 
didymes.  Herein  lies  one  of  the  strongest  arguments  of  those  of  us  who 
regard  the  epididymis  as  the  primary  focus  of  genital  tuberculosis. 
Also  Lapeyre42  has  noted  the  tendency  of  the  prostate  to  become 
encysted  in  fibrous  tissue  or  to  take  on  fibro-adipose  changes.  He 
found  19  such  cures  in  36  autopsies. 

The  condition  of  the  vas  deferens  varies  much.  For  a  certain  length 
of  time  it  may  show  no  tuberculosis  at  any  point.  Later  the  epididymal 
end  becomes  involved,  the  pathological  changes  gradually  tapering  off 
and  finally  disappearing  as  the  inguinal  canal  is  reached.  Involvement 
of  the  entire  vas  from  epididymis  to  prostate  is  evidently  rare,  if  indeed 
it  occurs  at  all.  This  statement  is  based  upon  many  observations  of 
my  own  and  those  of  K.  M.  Walker  and  Hawes,72  and  of  Lapeyre.42 
The  former,  believing  that  the  prostate  is  the  primary  focus  of  genital 
tuberculosis,  have  shown  that  the  infection  spreads  centrifugally  from 
the  prostate  along  the  lymphatics  of  the  vas.  Whether  this  also  occurs 
in  secondary  tuberculosis  of  the  prostate  I  am  unable  to  say,  but  I  see 
nothing  against  it.  At  any  rate,  we  have  the  fact  of  a  high  percentage 
of  azoospermia,  even  with  a  unilateral  process,  indicating  pathological 
changes  in,  and  obstruction  of,  the  vasa. 

K.  M.  Walker  and  Hawes72  have  shown  that  near  the  epididymis  and 
for  a  certain  distance  beyond,  sections  of  the  vas  show  a  ring  of  caseous 
material  in  the  mucous  lining,  while  the  outer  coats  are  intact.  Farther 
up  there  may  be  no  evidence  of  disease  at  all,  while  sections  near  the 
prostate  will  show  infiltration,  not  in  the  mucous  coat,  but  in  the  ad- 
ventia  and  more  particularly  in  the  lymphatics  surrounding  it. 


516  (iKMTAL    TUBERCULOSIS 

In  well-developed  cases  the  vas,  especially  its  scrotal  portion,  may 
present  numerous  and  fairly  regular  fusiform  swellings  along  its  course, 
rc>embling  a  chain  of  beads.  The  surrounding  tissues  and  other  ele- 
ments of  the  spermatic  cord  are  stiffened  and  adherent,  sometimes 
embedded  in  dense  scar  tissue. 

Microscopically,  according  to  George  Walker,70  the  initial  process 
"begins  just  underneath  the  mucosa  and  extends  upward,  invading, 
and  finally  completely  replacing,  the  epithelium.  In  this  manner  the 
whole  of  the  epithelial  layer  is  disintegrated  and  separated  from  the 
underlying  tissues.  The  lumen  then  becomes  filled  with  tuberculous 
debris,  similar  to  that  seen  in  the  prostatic  tubules  and  the  ducts  of  the 
epididymis." 

Tuberculosis  <,f  the  urethra  has  been  shown  to  be  rare  clinically,  but  it 
has  been  produced  experimentally  by  a  number  of  investigators.  George 
Walker's70  experimental  work  showed  three  stages  of  the  disease: 

1 .  Very  minute  tubercles. 

2.  Larger  tubercles  and  ulceration. 

3.  Caseous  infiltration. 

As  in  all  other  tuberculous  infections  of  the  genital  tract,  the  micro- 
scope shows  the  disease  to  begin  "just  beneath  the  epithelium,  where 
there  is  seen  a  small  cellular  aggregation,  which  later  invades  the  over- 
lying epithelium  and  forms  the  minute  tubercle  which  can  be  seen  with 
the- naked  eye;  an  erosion  of  the  epithelium  soon  occurs,  and  a  tiny 
ulcer  is  formed.  The  organisms  at  the  same  time  invade  the  submucous 
tissues,  and  finally  the  deeper  tissues,  with  the  formation  of  caseous 
infiltration  more  or  less  widespread." 

The  organisms  do  not  seem  to  invade  the  mucosa  directly,  but  it 
seems  probable  that  the  bacilli  penetrate  between  the  epithelial  cells  and 
lodge  immediately  under  them.  While  trauma  is  certainly  a  predispos- 
ing factor,  it  does  not  seem  to  be  essential  in  the  production  of  stricture. 

Tuberculosis  of  the  Glans  Penis. — I  have  already  shown  that  tuber- 
culosis of  the  glans  penis  is  occasionally  seen,  infection  at  the  time  of 
circumcision,  and,  as  some  believe,  coitus,  furnishing  most  examples. 
The  disease  takes  the  form  of  a  chronic  ulcer,  as  to  the  etiology  of 
which  all  other  organisms  must  be  excluded.  The  microscope  will 
reveal  the  nature  of  the  lesion. 

A  picture  of  the  widespread  havoc  produced  by  the  disease,  once  it 
has  gotten  outside  of  the  genito-urinary  tract,  was  presented  by  three 
of  our  patients  who  died  of  a  general  miliary  tuberculosis  following 
operation. 

In  one,  a  boy  aged  six  years,  with  a  unilateral  process  of  two  months' 
duration,  practically  every  organ  outside  the  genito-urinary  tract  was 
studded  with  miliary  tubercles.  The  excised  specimen  showed  tuber- 
culosis of  the  epididymis  (there  was  no  note  on  the  testicle),  but 
strangely  enough  bladder,  prostate,  seminal  vesicles,  and  the  remaining 
testis  and  epididymis  showed  no  evidences  of  infection.  There  was  a 
history  in  this  case  of  an  early  tuberculosis  of  lung  and  meninges,  and 
its  remains  were  found  at  autopsy. 


ETIOLOGY  517 

The  second  case,  aged  thirty-five  years,  had  a  more  or  less  active 
process  in  the  spine,  of  six  years'  duration.  The  epididymitis  was  right- 
sided,  and  of  unknown  age.  Autopsy  showed  old  tuberculosis  of  right 
kidney  and  ureter,  bladder,  pleura,  peritoneum,  bronchial  lymph 
glands,  spine,  seminal  vesicles,  and  prostate,  with  abscesses  in  the 
latter.  Both  testicles,  and  the  remaining  epididymis  were  healthy.  A 
cover-glass  preparation  of  the  seminal  fluid  showed  no  tubercle  bacilli. 

Our  third  case  occurred  in  a  man,  aged  twenty  years.  The  process 
was  again  right-sided,  its  duration  was  said  to  be  only  a  few  days,  and 
the  pathologist  reported  an  infection  of  testicle  as  well  as  of  epididymis. 
Autopsy  showed  a  general  miliary  tuberculosis,  including  the  meninges. 
The  bladder  was  uninfected,  as  well  as  the  left  seminal  vesicle,  and  the 
left  testicle  and  epididymis.  But  the  prostate  and  right  seminal  vesical 
contained  abscesses  and  caseous  foci. 

It  must  be  clear  from  this  discussion  of  the  pathogenesis  and  pathol- 
ogy of  genital  tuberculosis  that  many  points  are  unsettled  entirely,  or 
are  much  in  dispute.  This  ignorance  and  lack  of  agreement  is  due,  not 
so  much  to  a  paucity  of  single  or  brief  observations,  clinical  or  experi- 
mental, as  to  a  failure  to  study  all  the  available  material  from  beginning 
to  end.  The  situation  is  well  summed  up  by  Halle  and  Motz.25  They 
say: 

"A  detailed  mass  of  statistics,  patiently  followed  up,  on  pulmonary 
tuberculosis  on  the  one  hand,  and  on  genito-urinary  tuberculosis  on  the 
other,  from  the  earliest  clinical  symptoms  to  the  ultimate  issue,  will 
furnish  sufficient  and  certain  conclusions.  We  do  not  yet  possess  such 
a  mass  of  statistics." 

Etiology. — Although  the  tubercle  bacillus  is  the  organism  responsible 
for  the  disease  in  question,  certain  conditions  for  its  growth  must 
generally  be  fulfilled  before  it  can  gain  a  foothold  in  the  genital  tract. 
These  are: 

1 .  A  lowered  resistance  on  the  part  of  the  patient. 

2.  A  previously  existing  tuberculosis  of  some  other  part  of  the  body. 

3.  A  lowered  resistance  on  the  part  of  the  particular  organ  or  organs 
attacked. 

The  first  condition  may  be  assumed  to  exist  in  any  individual  acquir- 
ing tuberculosis. 

The  second  condition  I  have  shown  to  be  fulfilled  in  a  very  large 
percentage  of  cases. 

While  a  lowered  resistance  on  the  part  of  the  organ  first  attacked 
cannot  always  be  demonstrated,  certain  contributing  factors  can  be 
shown  to  exist,  or  to  have  recently  existed,  in  a  considerable  number  of 
cases. 

First  let  us  consider  trauma.  Tylinski66  and  others  have  shown 
conclusively,  in  animals,  that  this  has  a  distinct  influence  upon  the 
localization  of  a  tuberculous  process  in  an  organ.  In  our  material  a 
definite  history  of  injury  to  the  infected  organ  was  obtained  in  18  out 
of  a  possible  92  cases.  In  tuberculosis  elsewhere,  bone  for  example,  the 
outbreak  of  the  disease  is  very  frequently  preceded  by  an  injury. 


518  GENITAL   TUBERCULOSIS 

Second,  infections  of  the  epididymis  or  other  organs,  generally 
gonorrheal,  may  be  a  predisposing  cause  in  certain  instances.  Out  of 
95  cases,  of  the  series  just  mentioned,  34  (35  per  cent.)  had  had  an  in- 
fection of  the  epididymis  in  the  course  of  an  attack  of  gonorrhea.  A 
study  of  additional  material  has  shown  about  the  same  percentage. 
Whether  the  initial  epididymitis  was  of  gonorrheal  or  tuberculous  origin 
is  hard  to  say. 

Under  exciting  causes  we  should  include  ectopia  of  the  testicle.  This 
in  itself  may  lower  the  vitality  of  the  organ  or  subject  it  to  trauma. 
Ferron21  and  Le  Dentu43  have  reported  cases  of  tuberculosis  of  such  an 
organ. 

Tuberculosis  of  the  genital  tract  may  attack  the  infant  or  the  old 
man.  One  of  my  patients  was  eighteen  months  old;  another  was  a 
man  of  seventy-three.  Of  201  cases  of  genital  tuberculosis  collected 
by  Hesse,28  2  occurred  before  the  tenth  year,  1  between  seventy  and 
eighty,  and  1  after  the  eightieth  year.  Between  the  twentieth  and 
fortieth  years  he  found  118,  or  58.7  per  cent.,  and  from  forty  to  sixty 
years  49,  or  24.3  per  cent.;  in  other  words,  83  per  cent,  were  between 
twenty  and  sixty  years  old.  In  120  patients  (all  with  tuberculosis  of 
one  or  both  epididymes)  I  found  45  per  cent,  between  the  twenty- 
fifth  and  thirty-fifth  years.  Sixty-five  of  96  cases  reported  by  Keyes33 
were  between  twenty  and  forty  years  old.  Vignard  and  Thevenot68 
have  collected  several  cases  of  epididymal  tuberculosis  in  infants.  Two 
of  their  own  patients  were  respectively  fourteen  months  and  eleven 
months  old,  each  with  a  unilateral  process.  These  authors  cite  a  case 
in  a  patient  of  Cholmeley's68  six  months  old;  1  of  Hochsinger's68 
thirteen  months  old;  2  of  Swoboda's68  which  were  "nursing;"  4  of 
Launois's68  ranging  in  age  from  six  to  thirteen  months;  and  12  cases 
of  Julien's68  in  patients  under  two  years  of  age.  No  mention  is  made  of 
the  condition  of  the  prostate  or  vesicles  in  any  of  them.  I  have  found 
1  case,  reported  by  .Davids,18  in  a  man  eighty-five  years  old. 

I  have  already  indicated  the  frequency  with  which  secondary  tuber- 
culosis of  the  prostate  and  vesicles  is  found,  but  these  figures  apply 
chiefly  to  adults.  All  authors  agree  that  before  the  age  of  puberty 
these  organs  are  rarely  attacked.  Thus  Kantorowicz,31  in  57  cases  of 
epididymal  tuberculosis  in  children,  found  the  prostate  involved  but 
twice.  In  the  cases  under  twelve  to  fourteen  years  of  age  (6  in  all) 
coming  under  my  own  observation,  I  have  seen  no  prostatic  or  vesicular  • 
tuberculosis.  The  combined  experience  of  all  observers  shows  that 
prostatic  and  vesicular  tuberculosis  is  most  frequent  during  the  time  of 
the  greatest  activity  of  these  organs,  i.  e.,  from  about  the  twentieth  to 
the  fortieth  years. 

No  statistics  which  I  have  seen  give  the  incidence  of  marriage. 
Among  our  cases  66  per  cent,  were  married.  Not  that  this  is  strange, 
for  matrimony  usually  claims  this  number.  But  as  it  has  been  stated 
that  the  disease  may  be  conveyed  by  coitus,  I  note  that  in  not  one  of 
this  number  was  there  anything  to  suggest  that  marital  relations  were 
the  cause  of  contagion. 


CLINICAL  SIGNS  AND  SYMPTOMS  519 

The  etiological  factors  already  enumerated  for  tuberculosis  of  the 
epididymis,  will  apply  as  well  to  that  of  any  organ  of  the  genital  tract, 
whether  primarily  or  secondarily  involved. 

Clinical  Signs  and  Symptoms. — The  clinical  picture  of  tuberculosis  of 
the  epididymis  which  I  present,  is  based  upon  several  studies  of  a  group 
of  cases  from  the  Massachusetts  General  Hospital.  They  offer  for 
consideration  210  tuberculous  epididymes. 

Duration  of  the  Disease. — Fifty-three  per  cent,  of  the  patients  noted 
the  presence  of  the  disease  writhin  the  six  months  preceding  their 
appearance  at  the  hospital ;  in  a  fe\v  it  was  a  matter  of  only  days  or  weeks. 
In  72  per  cent,  the  infection  had  begun  within  the  previous  year. 
Thence  the  time  lengthens  until  from  five  to  eight  years  have  elapsed 
since  the  process  began,  and  during  which  the  smoldering  fire  has  more 
than  once  broken  into  flame,  only  to  be  quenched  with  a  poultice  or  a 
bag  of  ice.  Moreover,  nearly  half  of  the  patients  acknowledged  having 
submitted  to  more  or  less  minor  surgery  in  a  vain  effort  to  stamp  out 
the  disease.  This  interference  wras  usually  the  tapping,  often  repeat- 
edly, of  a  hydrocele,  which  so  frequently  accompanies  the  tuberculous 
process.  In  a  larger  number  than  one  would  like  to  see,  the  family 
doctor  had  merely  lanced  the  abscess,  thus  prematurely  giving  birth 
to  the  sinus  which  is  so  common. 

I  would  call  attention  to  the  fact  that  owing  to  the  insidious  nature  of 
the  disease,  the  patient  can  give,  in  most  cases,  no  accurate  answer  as  to 
the  duration  of  his  trouble.  In  this  respect  it  is  strikingly  different 
from  the  epididymitis  of  gonorrhea,  with  its  sudden  onslaught.  In  a 
few  instances  the  tuberculous  process  is  ushered  in  with  severe  pain, 
tenderness  and  swelling,  but  even  then  one  cannot  be  sure  that  the 
disease  has  not  been  going  on  for  some  time  unknown  to  the  patient. 

Side  Involved. — The  right  side  was  affected  in  59  (39.3  per  cent.), 
the  left  side  in  47  (31.3  per  cent.),  and  both  sides  (at  time  of  entrance) 
in  44  (29.3  per  cent.).  Sixteen  patients  (10.6  per  cent.),  after  operation 
upon  the  first  side,  subsequently  returned  writh  tuberculosis  of  the 
second  epididymis.  There  was,  therefore,  a  total  of  60  (40  per  cent.) 
with  bilateral  disease,  but  it  will  be  seen  that  the  number  of  relapses 
was  far  less  where  the  first  epididymis  had  been  previously  removed. 

Keyes33  in  a  series  of  87  cases  has  found  a  relapse  upon  the  second  side 
in  53 '(60.9  per  cent.). 

Konig36  noted  bilaterality  in  75  per  cent.,  wrhile  Beck30  puts  it  at  27 
per  cent.  v.  Bruns69  found  both  sides  involved  in  38  per  cent.,  while  in 
111  cases  from  the  Tubingen  Clinic  the  percentage  was  29.  Thus  the 
chances  of  escape  of  the  second  epididymis  are  seen  to  be  slim,  but  the 
management  of  the  first  epididymis  seems  to  influence  the  fate  of  its 
fellow.  Keyes33  says:  "Be  the  operation  ever  so  slight  or  ever  so 
radical"  relapse  upon  the  opposite  side  almost  inevitably  occurs.  My 
figures  show  that  relapse  is  less  apt  to  occur  if  the  first  epididymis  is 
operated  upon. 

Time  of  Involvement  of  the  Second  Epididymis. — The  time  of  involve- 
ment of  the  second  epididymis,  after  the  infection  of  the  first  side, 


520  GENITAL   TUBERCULOSIS 

varies  considerably,  but  is  usually  not  long  delayed.  In  my  series  this 
point  was  ascertained  in  49  patients.  In  26.5  per  cent,  it  took  place 
within  six  months,  while  in  the  first  twelve  months  38.7  per  cent,  were 
so  affected.  In  the  remaining  44.8  per  cent,  the  number  of  relapses 
dropped  steadily  after  the  first  year,  but  took  place  in  a  few  cases  as 
late  as  the  eighth  year.  Keyes' ;3  cases  show  that  46  out  of  53  infections 
of  the  second  side  occurred  within  the  first  year. 

Eight  of  my  cases  (16.3  per  cent.)  experienced  an  apparently  simul- 
taneous infection  of  both  epididymes,  ranging  in  duration  from  a  few 
weeks  to  eight  years  before  the  patient  sought  relief. 

It  is  therefore  clear  that  the  damage  to  the  second  side  is  an  early 
event  in  most  cases,  but  the  danger  is  not  entirely  eliminated  until  after 
the  lapse  of  at  least  eight  years.  It  is  also  quite  possible  that  the  infec- 
tion of  the  second  epididymis  may  be  so  slight  as  to  be  overlooked  at 
the  time  of  operation  upon  the  first  side.  This  possibility  is  to  be  con- 
sidered in  one's  statement  to  the  patient  of  the  condition  and  outlook 
of  the  second  epididymis. 

Results  of  the  Disease. — I  have  found  that  over  80  per  cent,  of  those 
questioned  on  the  subject  have  lost  weight.  In  some,  the  depletion  of 
flesh  and  strength  was  extreme,  sometimes  without  demonstrable 
tuberculosis  other  than  that  in  the  genital  tract.  Per  contra,  a  few 
individuals  had. put  on  weight  and  appeared  to  be  in  the  "pink"  of 
condition. 

Pain. — This  was  noted  in  about  60  per  cent,  of  my  cases.  It  was 
usually  mild,  often  trifling.  Generally  speaking,  it  was  located  in  the 
diseased  organ,  but  in  certain  instances  was  said  to  have  extended 
upward  to  the  groin  or  even  into  the  lumbar  region.  Radiation 
upward  was  usually  the  result  of  more  or  less  extensive  involvement  of 
the  vas  deferens  and  other  structures  of  the  spermatic  cord.  More 
often  than  not  its  presence  in  the  scrotum  could  be  accounted  for  by 
the  pressure  of  hydrocele  fluid  upon  an  acutely  inflamed  epididymis  or 
testicle.  In  spite  of  the  high  percentage  of  tuberculous  prostates  and 
vesicles,  I  have  noted  practically  no  pain  located  in  these  organs  or 
their  vicinity.  Pain  in  the  region  of  the  bladder  may,  however,  be 
experienced  during,  or  at  the  end  of  micturition,  and  is  found  in  cases  of 
bladder  tuberculosis  of  renal  or  prostatic  origin. 

During  one  of  the  characteristic  exacerbations  of  the  disease,  scrotal 
pain  may  be  intense,  abating  with  the  rupture  of  an  abscess  and  the 
establishment  of  fistula,  or  by  absorption  of  its  products.  Before  such 
an  outbreak  of  the  disease  there  may  be  no  pain  at  all. 

As  an  accompaniment  there  may  be  tenderness,  not  intense,  barring 
always  the  very  acute  cases,  but,  generally  speaking,  of  only  a  moderate 
degree,  its  intensity  doubtless  regulated  by  the  same  factors  which 
produce  pain. 

Fistula. — This  is  one  of  the  most  common  "earmarks"  of  tubercu- 
losis of  the  epididymis,  and  is  generally  to  be  found  in  the  skin  at,  or 
near,  the  lower  pole  of  the  organ.  Fistula?  at  the  upper  pole  are  seen 
occasional!  v. 


CLINICAL  SIGNS  AND  SYMPTOMS  521 

Seventy-seven  and  three-tenths  per  cent,  of  106  cases  in  my  series 
had  one  or  more  fistulse  in  the  scrotum.  More  often  than  not  they  were 
active ;  in  others  they  showed  a  volcanic  intermittency .  The  discharge 
is  profuse  at  times,  and  is  thin,  purulent,  and  yellowish  in  color. 

In  22.6  per  cent,  of  these  106  patients  the  scrotal  skin  was  more  or 
less  adherent  to  the  epididymis  and  in  some  cases  marked  the  site  of  an 
ancient  fistula,  long  since  inactive. 

That  fistulization  is  an  early  event  is  shown  by  an  examination  of  the 
82  patients  in  this  series  presenting  this  condition.  In  exactly  50 
per  cent,  the  abscess  had  formed,  ruptured  and  established  a  fistula 
within  six  months  after  the  onset  of  the  disease,  while  within  the  first 
year  this  had  taken  place  in  71  per  cent,  of  the  82  cases.  The  progress 
of  the  disease  is,  therefore,  not  slow  in  most  instances,  but  on  the  other 
hand,  I  have  seen  several  epididymes,  tuberculous  for  eight  or  nine 
years,  with  a  fistula  of  only  a  few  days'  duration. 

Fever. — An  elevation  of  temperature  before  operation  was  noted  in 
but  10  cases,  the  epididymes  in  these  being  in  a  state  of  acute 
inflammation. 

Condition  of  Prostate  and  Seminal  Vesicles. — Owing  to  the  proximity 
of  these  organs  one  to  another,  and  to  their  close  relationship,  I  believe 
that  when  the  prostate  is  tuberculous,  the  seminal  vesicles  are  also 
involved,  or  that  they  may  be  so  regarded  for  clinical  purposes. 

The  effect  of  the  disease  upon  these  organs  has  already  been  dwelt 
upon  at  some  length  and  I  have  shown  that  76  of  101  rectal  examina- 
tions in  my  series  of  cases  revealed  tuberculosis  of  the  prostate  and 
seminal  vesicles. 

A  more  detailed  study  of  these  cases  has  shown  that  where  prostate 
and  vesicles  were  regarded  as  tuberculous,  epididymitis  was  unilateral 
in  38  and  bilateral  in  38;  while  in  the  negative  cases  one  epididymis  was 
tuberculous  in  16,  and  both  were  involved  in  9.  From  which  it  follows 
that  prostate  and  seminal  vesicles  become  readily  involved  in  the  pres- 
ence of  one  tuberculous  epididymis,  and  before  infection  of  the  opposite 
side  has  had  time  to  take  place.  In  substantiation  of  this  point  I  have 
data  as  to  the  condition  of  the  prostate  and  vesicles  and  the  known 
duration  of  the  epididymal  infection  in  99  cases.  In  the  first  six  months 
of  the  disease  prostate  and  vesicles  were  found  to  be  infected  in  40  and 
healthy  in  15;  in  the  period  from  six  months  to  one  year  14  were  posi- 
tive and  3  negative.  After  the  first  year,  and,  in  some  cases,  after  a 
period  of  six  or  seven  years,  prostate  and  vesicles  were  tuberculous  in 
20  and  negative  in  7.  Thus  in  the  first  six  months  of  the  disease  30  per 
cent,  are  infected,  and  in  the  first  year  54  per  cent.  On  the  other  hand, 
one  must  not  lose  sight  of  the  7  prostates  which  are  said  to  have  held  the 
enemy  at  bay  for  periods  ranging  all  the  way  from  one  to  six  or  seven 
years. 

Bladder  Symptoms  and  Condition  of  the  Urine. — With  so  frequent 
and  early  an  infection  of  prostate  and  vesicles,  the  bladder  neck  be- 
comes irritable  at  an  early  date.  In  45  patients  (35  per  cent.)  urinary 
symptoms  such  as  frequency,  dysuria,  and  urgency  were  recorded,  while 


522  GENITAL   TUBERCULOSIS 

43  per  cent,  of  104  urines  contained  pus,  blood  and  albumin.  Also,  out 
of  10  urines  with  which  the  guinea-pig  was  inoculated,  8  showed  the 
presence  of  the  tubercle  bacillus.  As  in  the  absence  of  symptoms  point- 
ing to  the  kidney,  cystoscopy  and  ureteral  catheterization  have  seemed 
to  us  to  be  unwise,  it  is  barely  possible  that  some  of  these  tuberculous 
urines  were  of  renal  origin.  In  this  series  there  were  recognized  and 
operated  upon,  18  cases  of  renal  tuberculosis,  occurring  at  some  time 
or  other  in  the  course  of  the  epididymitis.  The  8  tuberculous  urines 
already  referred  to  include  none  of  these  cases.  It  is  probable,  there- 
fore, that  the  pathological  urine  and  the  bladder  symptoms  took  origin 
from  the  prostate.  This  belief  is  substantiated  by  the  observations  of 
Lowenstein45  who,  in  18  cases  of  epididymal  tuberculosis,  found  tubercle 
bacilli  in  the  urines  of  all.  Renal  tuberculosis  was  excluded  as  the 
source  in  every  case  and  the  prostate  was  regarded  as  accountable  for 
the  bacilli. 

Accompanying  the  bladder  symptoms  and  the  pathological  urines  in 
this  series,  prostate  and  vesicles  were  recorded  as  tuberculous  in  28  and 
negative  in  4.  Furthermore,  the  relation  of  bladder  irritability  to  the 
known  existence  of  the  epididymitis  has  been  looked  into  in  43  cases. 
In  21 ,  or  49  per  cent.,  urinary  symptoms  were  present  in  the  first  six 
months  of  the  disease,  whereas,  in  the  first  year  the  figures  jump  to 
27,  or  62  per  cent. 

Condition  of  the  Testicle. — Sixty-six  of  the  testicles  in  this  series  were 
found  to  be  tuberculous.  Forty-four  occurred  in  unilateral  cases,  and 
only  22  where  the  process  was  bilateral.  In  other  words,  testicular 
infection  is  generally  found  in  the  early  months  of  the  epididymitis. 
Thus  60.6  per  cent,  of  the  total  number  had  become  tuberculous  in  the 
first  six  months  of  the  disease,  and  83.3  per  cent,  in  the  first  year.  That 
the  testicle  may  resist  invasion  for  a  long  period  of  time  is  illustrated  by 
several  cases  in  which  the  epididymal  disease  had  existed  for  from  five  to 
eight  years.  These  observations  differ  from  those  of  Haas24  and 
Lapeyre^2  who  found  the  percentage  of  infected  testicles  to  be  progress- 
ively greater  with  the  age  of  the  epididymitis. 

Condition  of  the  Vas  Deferen-s.—lt  is  unfortunate  that  physical  ex- 
amination often  overlooks  an  important  and  an  interesting  feature  of  a 
case.  This  has  been  true  with  the  vas  deferens.  I  have  notes  as  to  its 
condition  (mostly  macroscopic)  in  46  instances,  26  of  these  being  on 
the  side  last  involved.  Of  the  latter,  16  (61.5  per  cent.)  wrere  thickened 
for  a  greater  or  less  distance  upward  from  the  epididymis,  in  some 
instances  this  being  extreme.  Fifteen  out  of  20  vasa  (75  per  cent.)  of 
the  first  epididymis  to  be  involved  were  regarded  as  tuberculous. 

While  these  figures  are  insufficient  for  accurate  deduction,  the  fact 
that  the  vas  of  the  epididymis  last  involved  is  less  often  diseased  than  is 
its  fellow,  would  indicate  that  the  tubercle  bacillus  reached  the  second 
side  by  the  blood  stream,  or  by  the  lymphatics. 

Sex  Function. — I  have  mentioned  elsewhere  that  85  per  cent,  of  the 
patients  whose  semen  has  been  examined  have  shown  azoospermia, 
even  with  only  one  epididymis  involved,  an  observation  supported  by 


DIAGNOSIS  523 

the  experience  of  Keyes.33  Further  studies  confirm  this  view.  This 
condition  is  probably  accounted  for  by  an  obstruction  of  the  vasa 
deferentia,  that  on  the  still  healthy  side  being  doubtless  involved  at  its 
urethral  extremity  by  extension  of  the  disease  from  the  prostate. 

Masculinity  does  not  seem  to  be  impaired  even  after  double  orchi- 
dectomy.  Several  of  our  cases  bear  out  this  statement,  and  Simon60 
says  the  sex  function  remained  normal  for  from  ten  to  twenty  years 
in  29  of  his  cases  of  double  orchidectomy  for  tuberculosis.  It  has  also 
been  shown  that  spermatogenesis  is  persistent,  even  in  a  testicle  riddled 
writh  tuberculosis. 

The  symptomatology  of  primary  prostatic  tuberculosis  is  little  differ- 
ent from  that  which  is  secondary  to  epididymal  disease.  The  bladder 
irritability,  the  character  of  the  urine  and  the  course  of  the  disease 
present  no  striking  differences. 

Difficulty  of  urination,  or  possibly  retention,  plus  the  evidences  of 
tuberculosis,  would  characterize  a  tuberculous  stricture  of  the  urethra. 
It  has  been  my  experience  to  find  this  lesion  accompanying  renal 
tuberculosis. 

A  chronic  ulcer  of  the  glans  penis,  not  associated  with  venereal 
disease,  might  lead  one  to  suspect  tuberculosis.  Microscopic  examina- 
tion would  confirm  the  suspicion. 

Diagnosis. — The  diagnosis  of  a  typical  case  of  tuberculosis  of  the 
epididymis  is  not  difficult.  Induration,  enlargement,  and  nodularity  of 
the  organ,  especially  at  its  lower  pole,  associated  with  little  or  no  pain 
or  tenderness,  is  the  usual  clinical  picture.  If,  in  addition,  one  finds  the 
corresponding  vas  deferens  enlarged  and  irregularly  thickened,  espe- 
cially at  its  epididymal  end,  and  if  the  prostate  and  the  seminal  vesicles 
(particularly  on  the  same  side  as  the  diseased  epididymis)  are  likewise 
affected,  the  case  is  undoubtedly  one  of  tuberculosis.  The  chronicity  of 
the  disease,  or  its  bilaterality  would  help  to  confirm  this  diagnosis.  If, 
also,  there  is  bladder  irritability  and  a  hazy  urine  containing  pus  and 
tubercle  bacilli,  all  doubt  is  removed.  The  diagnosis  is  equally  certain 
in  the  presence  of  an  active  fistula  or  the  dimpled  scar  of  one  long  healed. 

At  other  times  the  diagnosis  must  be  in  doubt  until  one  or  more  of 
the  features  enumerated  above  comes  to  the  rescue,  or  until  removal  of 
the  epididymis  and  microscopic  examination  reveals  the  truth.  The 
acute  tuberculous  epididymis  may  well  be  mistaken  for  that  of  gonor- 
rhea or  a  pyogenic  infection.  Only  a  careful  history,  painstaking  exami- 
nation, and  adequate  observation  wrill  solve  the  problem. 

But  it  should  not  be  forgotten  that  an  attack  of  gonorrhea  which  has 
escaped  the  patient's  memory,  an  unobserved  syphilitic  infection  of 
long  ago,  an  infection  of  the  epididymis  in  the  course  of  a  colon  bacillus 
cystitis,  or  writh  a  pyogenic  organism  from  some  septic  focus  elsewhere 
in  the  body,  may  each  produce  a  picture  not  unlike  that  of  tuberculosis. 

One  can  never  be  certain  of  the  condition  of  the  testicle.  An  in- 
crease in  the  size  of  the  organ,  with  nodularity  of  its  surface,  may  mean 
disease,  or  may  signify  only  an  invasion  of  the  overlying  tunica. 

If  the  evidence  is  in  favor  of  tuberculosis,  or  if  the  disease  is  clearly 


524  GEXITAL    TUBERCULOSIS 

progressing,  an  exploratory  operation  should  be  advised.  The  diag- 
nosis of  lesions  within  the  scrotum  are  so  uncertain,  even  when  made  by 
the  most  expert, that  the  patient  should  be  given  the  benefit  of  the  doubt. 
If  he  has  tuberculosis  he  is  entitled  to  the  earliest  treatment;  if  he  has 
not  tuberculosis  he  is  entitled  to  the  joy  which  that  knowledge  brings. 

Prognosis.* — I  have  already  pointed  out  the  disastrous  results  of 
genital  tuberculosis  and  their  rapidity  of  occurrence.  It  has  been 
shown  that  the  second  epididymis  is  attacked  in  26.5  per  cent,  within 
the  first  six  months  after  the  involvement  of  the  first  side;  that  the 
disease  invades  prostate  and  vesicles  in  30  per  cent,  within  the  same 
time;  and  that  testicular  tuberculosis  within  this  period  is  found  in 
60.6  per  cent.  If  one  adds  to  these  misfortunes  the  annoyance  of  blad- 
der irritability,  and  the  affliction  of  sterility,  the  outlook  is  indeed 
gloomy.  It  is  also  to  be  remembered  that  a  very  large  proportion  of 
patients  have  the  proverbial  axe  hanging  over  them  in  the  form  of 
tuberculosis  of  other  organs. 

Let  us  now  see  what  encouragement  can  be  held  out  to  the  patient 
with  tuberculosis  of  the  epididymis.  I  have  traced  113  patients  from 
one  to  twenty-five  years  after  operation.  Over  27  per  cent,  have  died 
of  some  form  of  tuberculosis.  Within  a  period  of  six  years  after  opera- 
tion 41  per  cent,  of  58  patients  have  died  of  this  disease.  Of  the 
deaths  from  tuberculosis,  14.2  per  cent,  occurred  within  one  month, 
32.1  per  cent,  within  six  months,  and  50  per  cent,  within  one  year 
after  operation.  During  the  first  six  years  85  per  cent,  died,  while 
between  the  ninth  and  eleventh  years  10.7  per  cent,  succumbed. 
Miliary,  renal  and  lung  tuberculosis  were,  in  order,  the  final  types  of 
the  disease.  A  large  majority  of  those  dying  of  tuberculosis  had  had 
one  or  more  outbreaks  of  the  disease  both  before  and  after  operation. 
My  experience  warrants  the  conclusion  that  until  at  least  ten  years 
have  elapsed  after  operation,  no  patient  can  be  said  to  be  cured  of 
genital  tuberculosis.  The  high  percentage  (14.2)  of  the  total  deaths 
from  tuberculosis  within  a  month  after  operation,  in  the  hospital, 
deserves  a  word  of  explanation.  There  were  actually  four  deaths  within 
this  period,  giving  an  operative  mortality  of  2.66  per  cent,  for  the 
total  number  of  150  cases.  Operation  was  performed  in  all  under 
ether,  an  anesthetic  which  is  generally  recognized  as  likely  to  stir  up 
an  otherwise  quiescent  focus  of  tuberculosis  in  the  lung.  I  am  con- 
vinced that  the  employment  of  a  local  anesthetic  (novocain)  or  of 
gas-oxygen  anesthesia,  as  is  at  present  usually  done,  will  eventually 
reduce  this  high  operative  mortality. 

The  records  of  the  60  patients  now  living  (53  per  cent.)  show  a  much 
smaller  percentage  of  other  tuberculous  processes  before  operation 
than  do  those  of  the  dead,  but  many  of  them  have  since  developed 
other  foci.  As  81  per  cent,  of  those  examined  and  28.5  per  cent,  of 
those  reached  only  by  letter  are  still  within  the  six-year  period,  in  which 
I  found  that  85  per  cent,  of  deaths  occurred,  it  is  to  be  expected  that  the 

*  For  the  views  here  expressed  I  shall  quote  freely  from  my  paper  on  "The  Ultimate 
Results  of  Genital  Tuberculosis  in  the  Male."6 


PROGNOSIS  525 

deaths  from  tuberculosis  in  this  group  are  not  yet  at  an  end.  The  long 
life  and  good  general  condition  of  many  of  the  patients,  even  though 
suffering  from  repeated  outbreaks  of  the  disease,  shows  that  the  sur- 
vival of  the  patient  depends  largely  upon  his  ability  to  immunize 
himself  to  the  disease.  Taken  all  in  all,  the  odds  are  against  the 
patient.  The  longer  he  can  live  and  fight  down  any  particular  outburst 
of  the  disease  the  better  able  he  is,  in  most  instances,  to  overcome  the 
next  exacerbation. 

The  facts  here  presented  are  somewhat  different  from  those  of  other 
writers.  Lapeyre42  says  that  75  per  cent,  of  his  cases  are  cured,  and  that 
a  survival  of  the  patients  of  from  four  to  ten  years  after  operation  is  to 
be  expected. 

Simon60  has  followed  92  cases  from  the  Heidelberg  Clinic.  Fifty-four 
were  found  to  be  alive  and  free  from  tuberculosis,  but  this  disease  had 
claimed  20  of  the  33  who  had  died.  Lung  tuberculosis  figured  largely 
in  the  latter,  and  was  frequently  found  in  those  still  alive. 

v.  Brims69  found  bilateral  epididymal  tuberculosis  in  38  per  cent,  of 
his  cases.  Of  those  having  operation  on  one  side,  23  per  cent,  returned 
within  three  years  for  the  removal  of  the  second  testicle.  Of  the  single 
castrations,  12  per  cent,  died  of  urogenital  tuberculosis,  and  15  per  cent, 
died  of  tuberculosis  of  other  organs,  especially  the  lungs.  Forty-six 
per  cent,  of  the  unilateral  cases  were  cured  after  three  to  thirty-four 
years. 

Of  the  double  castrations,  15  per  cent,  died  of  urogenital  tuberculosis, 
and  25  per  cent,  of  tuberculosis  of  other  organs,  the  lungs  again  being 
most  often  attacked.  Fifty-six  per  cent,  of  this  group  were  cured  after 
three  to  thirty  years. 

Berger12  has  reported  60.4  per  cent,  of  cures  after  single  or  double 
castration,  but  does  not  state  the" time  elapsing  after  operation. 

Among  the  cases  analyzed  here,  epididymectomy,  partial  or  complete, 
single  or  double,  was  performed  78  times.  I  have  stated  elsewhere  on 
several  occasions,  as  evidence  of  the  efficacy  of  this  operation,  that 
not  one  of  these  patients  had  been  obliged  to  submit  to  subsequent 
orchidectomy.  This  record  is  now  broken  by  2  cases,  from  whom  it  was 
deemed  necessary  to  remove  the  testicle  within  one  month  and  two 
months  respectively  after  epididymectomy.  The  pathologist  reported 
tuberculosis  of  one  gland ;  the  other  showed  only  a  round-cell  infiltra- 
tion, and  its  removal  was  clearly  an  error  of  surgical  judgment.  At 
the  first  operation  there  was  no  evidence  in  either  case  that  the  testicle 
was  diseased.  What  better  proof  is  there  of  the  efficacy  of  epididy- 
mectomy, even  though  we  know  that  in  certain  of  them  a  more  or  less 
infected  testicle  was  allowed  to  remain  ? 

I  find  that  this  experience  agrees  with  that  of  Lapeyre,42  Keyes33  and 
Marinesco,46  although  the  latter  has  had  6  of  his  unilateral  epididy- 
mectomies  return  within  two  months  for  a  secondary  castration.  The 
size,  shape,  consistency,  and,  in  most  cases,  the  sensation  of  the  testicle 
are  unaffected,  and  the  benefit  to  the  patient  morally  and  physically  is 
well  worth  the  very  slight  chance  of  the  necessity  of  a  secondary  orchi- 


526  GEN  IT A L    T UBERC ULOSIS 

dectomy.     I  think  we  are  apt  to  regard  altogether  too  lightly  the  great 
value  of  the  internal  secretion  of  the  testicle. 

In  this  connection  it  may  be  mentioned  that  a  tuberculous  tunica 
vaginalis  may  assume  an  unexpected  activity  after  epididymectomy. 
The  clinical  picture  is  very  like  that  of  an  orchitis,  and  in  this  belief 
orchidectomy  may  be  advised  or  even  done.  There  have  been  3  such 
in  my  series,  but  in  each  a  careful  investigation  of  the  situation,  and  the 
free  use  of  the  curette  has  saved  the  testicle. 

The  very  great  incidence  of  sterility,  even  with  unilateral  epididymal 
tuberculosis,  has  been  pointed  out.  I  have  no  evidence  that  this  con- 
dition is  done  away  with,  in  spite  of  an  otherwise  successful  issue  of  the 
case.  An  involvement  of  one  or  both  testicles  does  not  seem  to  affect 
potency,  and  this  may  continue  even  after  bilateral  orchidectomy. 

Postoperative  sinuses  of  the  groin  or  scrotum  are  now  a  negligible 
factor  in  our  experience.  If  the  vas  is  divided  in  the  region  of  the 
external  ring,  where  it  has  been  shown  to  be  tuberculous  in  many 
cases,  a  sinus  of  several  weeks'  or  months'  duration  is  not  unusual.  By 
dividing  the  vas  well  over  the  pelvic  brim,  at  a  point  where,  with  few 
exceptions,  it  is  free  from  disease,  no  sinus  will  occur.  Since  the 
introduction  of  the  technic  of  epididymovasectomy,  to  be  described 
later,  I  know  of  no  case  in  which  even  a  temporary  sinus  from  the 
stump  of  the  vas  has  occurred.  In  a  few  instances  there  have  been 
small  and  short-lived  sinuses  of  the  scrotum,  but  they  have  readily 
yielded  to  time,  tuberculin  and  hygiene. 

In  69  of  the  113  patients  whom  I  have  followed,  the  prostate  and 
seminal  vesicles  were  found  to  be  tuberculous  at  the  time  of  entrance  to 
the  hospital.  I  have  since  examined  many  of  them  at  various  intervals 
of  time  after  operation.  In  most  instances  the  induration,  nodularity, 
and  tenderness,  present  before  operation,  has  subsequently  disappeared 
entirely  or  much  decreased.  In  a  few,  the  condition  is  the  same  as 
before  operation.  In  2  instances  an  abscess  subsequently  formed  and 
opened  spontaneously,  with  the  establishment  of  a  perineal  fistula, 
from  which  urine  has  leaked  at  times. 

The  tuberculous  stricture  has  a  habit  of  closing  down  rapidly  after 
dilatation  or  division,  much  more  than  is  the  case  with  one  of  gonorrheal 
origin. 

The  facts  here  presented  are  based  upon  operated  cases.  They 
demonstrate  beyond  question  that,  taken  all  in  all,  the  odds  are  against 
the  patient. 

I  have  but  few  data  of  patients  who  have  had  no  operative  treatment. 
There  were  eleven  such  cases  in  the  material  that  I  have  studied', 
which  were  not  operated  upon  for  one  reason  or  another.  None,  so  far 
as  I  am  aware,  were  given  tuberculin  or  any  special  hygienic  care.  Six 
died  from  tuberculosis,  1  three  months  later,  another  after  ten  years; 
1  was  "well"  a  year  later;  1  died  of  "apoplexy"  shortly  after;  3  cannot 
be  traced.  While  these  figures  are  too  small  to  be  of  much  value,  they 
show  that  the  outcome  was  not  brilliant.  Keyes33  found  30  per  cent, 
of  "cures"  in  34  cases  without  operation  and  watched  for  more  than 


TREATMENT  527 

three  years.  He  says,  "They  would  not  be  verified  if  the  cases  were 
more  numerous,"  and  I  am  inclined  to  agree  with  him. 

While  we  have  a  high  opinion  of  tuberculin  as  an  adjunct  to  the 
postoperative  care  of  genital  tuberculosis,  we  have  advised  strongly 
against  it  as  a  substitute  for  operation.  Some  of  the  French  writers, 
on  the  other  hand,  have  much  to  say  in  its  favor  in  the  expectant  treat- 
ment of  the  disease.  Lelongt44  quotes  the  statistics  of  Mantoux,  based 
on  70  cases  of  genital  tuberculosis  treated  in  this  way.  He  thinks  they 
are  encouraging  when  one  considers  that  they  had  no  hope  of  improve- 
ment by  surgical  treatment.  These  cases  showed  cure  in  33  per  cent., 
much  improvement  in  48  per  cent.,  no  change  in  11  per  cent.,  and 
deaths  in  8  per  cent. 

Xo  details  are  given,  especially  of  the  time  during  which  the  cases 
were  observed.  Without  definite  facts  one  hesitates  to  accept  the 
claims. 

Treatment. — This  may  be  divided  into  expectant,  conservative,  and 
radical,  tuberculin  being  an  important  adjunct  throughout. 

Expectant  treatment  should  be  undertaken  only  in  those  cases  whefe 
operative  measures  are  refused  or,  for  some  reason,  impossible.  It 
means  putting  the  patient  under  the  very  best  of  hygienic  conditions  as 
regards  fresh  air,  sunlight,  food,  work  and  sleep.  Tuberculin  should  be 
given  regularly  and  intelligently.  It  means  the  tapping,  when  indi- 
cated, of  the  hydrocele  which  so  often  accompanies  the  tuberculous 
epididymis,  and,  to  those  who  have  a  pathological  urine  or  bladder 
symptoms,  sandalwood  oil  should  be  administered  (10  minims  thrice 
daily).*  If  abscesses  of  the  scrotum  occur  they  should  be  incised  and 
properly  drained. 

By  conservative  treatment  I  refer  to  the  removal  of  the  epididymis, 
together  with  as  much  of  the  vas  as  is  easily  accessible,  and,  where 
necessary,  the  testicle. 

The  history  of  operations  upon  the  epididymis  has  been  written  by 
Marinesco/6  Recognizing  the  evil  effects,  mental  and  physical,  of 
castration,  especially  when  bilateral,  and  acknowledging  the  im- 
portance of  the  epididymis  in  genital  tuberculosis,  Berard,46  in  1834, 
performed  the  first  partial  epididymectomy.  In  1851  Malgaigne,46  as 
well  as  Jobert46  and  de  Lamballe/6  were  performing  a  complete  and 
extensive  excision  of  the  epididymis.  Bardenheuer,46  in  1880,  is  credited 
with  the  first  real  description  of  epididymectomy,  and  he  showed  its 
value  in  a  series  of  34  cases. 

Villeneuve46  did  the  first  epididymectomy  in  France  in  1889,  and 
emphasized  the  great  value  of  the  testicle  for  its  internal  secretion,  as 
well  as  for  its  psychic  effect. 

While  the  French  surgeons  were  doing  their  utmost  to  preserve  the 
testicle,  the  Germans,  with  one  or  two  exceptions,  continued  their  habit 

*  A  very  efficient  substitute  for  sandalwood  oil  is  a  capsule  composed  of  guaiacol 
carbonate  gr.  iij,  powdered  pepsin  (1  to  3000)  gr.  j,  calcium  carbonate  (C.P.)  gr.  x. 
This  is  given  thrice  daily  after  meals.  All  preparations  containing  hexamethylenamin 
are  likely  to  aggravate  bladder  symptoms. 


528  GENITAL  TUBERCULOSIS 

of  promiscuous  castration.  Unfortunately  their  example  has  been 
copied  all  too  widely  and  even  today  the  general  surgeon,  otherwise 
sound  and  conservative,  removes  the  testicle,  when  by  a  simple  opera- 
tion this  valuable  organ  can  be  preserved  to  the  patient. 

For  the  technic  of  epididymectomy,  better  called  epididymovasec- 
tomy,  we  are  indebted  to  Cabot,15  whose  description  of  the  operation 
I  quote.  This  procedure  can  be  done  in  most  cases  with  novocain 
local  anesthesia,  but  in  a  few  patients,  with  an  acutely  inflamed 
scrotum,  or  of  neurotic  temperament,  gas-oxygen  anesthesia  is  prefer- 
able. The  use-of  ether  is  strongly  condemned. 

"  The  local  preparation  of  the  patient  should  involve  the  skin  of  the 
scrotum  and  the  groin  of  the  corresponding  side  if  the  disease  is  unilat- 
eral. An  incision  is  made  over  the  epididymis  about  two  inches  long. 
If  sinuses  are  present  they  should  be  circumscribed  by  the  incision. 
This  is  carried  down  to  and  opens  the  tunica  vaginalis,  which  will  in 
many  cases  be  found  adherent  to  the  testicle  and  must  be  separated  by 
dissection.  The  testicle  and  epididymis  are  delivered  from  the  wound. 
The  epididymis  is  then  separated  from  the  testicle  by  a  scissors  dissec- 
tion, as  in  this  way  the  vessels  which  lie  behind  the  epididymis  are  less 
likely  to  be  destroyed.  The  separation  should  be  begun  at  the  upper 
pole  and  carried  downward,  the  epididymis  being  separated  from 
within  outward.  When  it  is  free.the  lower  inch  or  two  of  the  vas  should 
be  stripped  up  by  blunt  dissection  from  the  structures  of  the  cord.  A 
curved  clamp  is  then  applied  to  the  vas  and  the  epididymis  and  the 
lower  inch  or  two  of  the  vas  cut  away.  The  vas  is  then  stripped  up  by 
blunt  dissection  with  the  fingers  so  as  to  free  it  from  the  structures  of 
the  cord  up  to  the  external  inguinal  ring.  Guided  by  the  finger,  the 
clamp  on  the  lower  end  of  the  vas  is  then  passed  up  to  the  external 
ring  and  carefully  inserted  into  the  canal,  care  being  taken  to  avoid 
pushing  it  in  front  of  the  canal  between  the  fascia  and  the  fat.  The 
clamp  is  then  pushed  upward  and  outward,  following  the  line  of  the 
inguinal  canal  until  its  tip  lies  directly  beneath  the  fascia  at  the  level  of 
the  internal  inguinal  ring.  The  handle  of  the  clamp  is  then  strongly 
depressed,  bringing  the  point  snugly  against  the  skin.  An  incision 
not  over  half  an  inch  in  length  is  then  made  on  the  point  of  the  clamp, 
which  is  then  pushed  out  through  this  incision  carrying  with  it  the 
distal  end  of  the  vas  (Fig.  225).  The  vas  is  then  picked  up,  the  traction 
is  made  so  as  to  pull  out  the  portion  lying  in  the  canal  so  that  the 
remaining  portion  dives  vertically  into  the  wound  and  over  the  brim  of 
the  pelvis.  The  finger  is  then  inserted  into  the  little  wound,  as  shown 
in  Fig.  226,  and  the  vas  is  freed  as  far  as  the  finger  can  reach,  making 
steady  traction  during  this  process.  A  right-angled  clamp  is  then 
applied  to  the  vas  at  the  lowest  accessible  point.  It  is  divided,  cauter- 
ized with  phenol  (carbolic  acid)  and  dropped  back.  The  wound  in  the 
groin  is  closed  with  one  catgut  suture  in  the  fascia,  with  a  silkworm-gut 
stitch  in  the  skin.  The  operation  is  completed  by  the  careful  ligation 
of  any  bleeding-points  in  the  scrotum.  Any  apparent  foci  in  the  testicle 
are  eradicated  with  a  curette.  The  wound  is  painted  with  tincture  of 


TREATMENT 


iodin  and  closed  with  a  subcuticular  suture  of  silkworm  gut,  leaving  a 
small  protective-tissue  drain  at  the  lower  angle.  This  drain  has  been 
found  to  shorten  convalescence  by  giving  free  exit  to  the  serum  which 


FIG.  225. — Vas  held  in  curved  clamp  which  has  been  passed  up  into  the  inguinal 
canal  and  is  making  its  exit  through  a  small  incision  opposite  the  internal  inguinal 
ring. 


FIG.  226. — Tension  is  made  on  the  vas  by  the  operator's  left  hand,  while  with  his 
right  index  finger  in  the  inguinal  incision,  he  frees  the  vas  over  the  pelvic  brim. 
M  u     i — 34 


5)5(1  CEXITAL    TUBERCULOSIS 

necessarily  oozes  from  the  raw  surface,  the  amount  of  which  is  con- 
siderably increased  by  the  application  of  iodin.  The  dressing  is  held  in 
place  by  the  application  of  an  Alexander  bandage,  one  of  the  many 
devices  of  the  late  Samuel  Alexander,  which  has  been  a  boon  to  the 
genito-urinary  surgeon.  The  drain  can  generally  be  removed  in  forty- 
eight  hours  and  the  patient  may  be  up  and  about  in  two  or  three  days. 
The  after-treatment  should  include  all  of  the  general  hygienic  measures 
suitable  for  patients  with  tuberculosis,  including  the  routine  use  of 
tuberculin  and  the  routine  use  of  sandalwood  oil  in  cases  in  which  there 
is  involvement  of  the  prostate." 

As  regards  the  testicle,  I  would  add  that  in  suspicious  cases  I  am  in 
accord  with  Lapeyre,42  that  an  exploratory  orchidotomy,  partial  or 
complete,  is  not  only  justifiable,  but  harmless. 

Sinuses  at  the  point  of  division  of  the  vas  deferens  do  not  occur,  and 
those  of  the  scrotum  are  insignificant  and  infrequent.  I  do  not  hesi- 
tate to  say  that  this  operation  marks  one  of  the  most  important  ad- 
vances in  the  surgery  of  the  genital  tract. 

Our  attitude  toward  the  second  epididymis,  even  though  it  be  healthy, 
should  be  carefully  considered.  I  said  in  191 1,3  "knowing  the  life 
history  of  the  disease,  and  finding  the  patient  already  sterile,  as  we  shall 
in  a  very  large  number  of  cases,  we  feel  justified  in  advocating  the 
removal  of  both  epididymes  and  vasa  at  one  sitting." 

While  this  may  appear  to  be  a  radical  policy,  it  rests  upon  a  firm 
basis  of  surgical  pathology.  The  beneficial  effects  of  double  section  of 
the  vas,  upon  vesicular  and  prostatic  lesions  has  been  shown  by 
Lapeyre42  and  Israel.42 

According  to  Legueu,42  "  in  the  presence  of  bilateral  vesicular  disease 
the  second  vas  should  be  systematically  ligated  in  the  course  of  a  uni- 
lateral operation.  We  then  avoid  at  once  the  infection  of  the  healthy 
testicle  and  serious  involvement  of  the  prostate."  Lapeyre,42  on  the 
other  hand,  takes  the  more  radical  view.  He  has  resected  the  healthy 
vas  for  ,3  years  as  a  routine  practice  and  says  that  "after  double 
section  of  the  vas,  as  after  double  castration,  the  cure  of  vesiculoprosta- 
titis  is  more  frequent  than  after  a  unilateral  operation."  If  it  is  proved 
that  the  patient  is  already  sterile,  I  regard  this  procedure  as  desirable. 

Radical  treatment  involves  the  removal,  not  only  of  the  epididymis, 
but  also  of  the  prostate  and  seminal  vesicles,  but  we  have  seen  no  case 
in  which  this  extensive  operation  was  deemed  necessary  or  wise.  In  fact, 
we  cannot  condemn  too  strongly  this  extremely  radical  step.  White- 
side73  is  perhaps  the  most  ardent  advocate  of  this  procedure  in  this 
country,  but  grants  that  it  should  be  done  only  in  "selected  advanced 
cases."  He  has  recently  reported  22  such  cases,  operated  on  within 
the  past  six  years.  Four  were  "absolutely  cured,"  and  there  has 
been  no  operative  mortality.  European  surgeons  have  been  more 
favorable  to  the  radical  operation.  ITlmann,42  in  1889,  performed 
epididymo-vaso-vesiculectomy,  but  the  operation  met  with  little  favor 
on  account  of  its  dangers  and  difficulties.  Baudet7  has  since  popular- 
ized it  by  making  use  of  the  inguinal  route.  In  his  hands  the  mor- 


TREATMENT  531 

tality  has  been  practically  nil,  and  he  has  reported  46  cures,  out  of  58, 
after  the  lapse  of  from  four  to  six  years. 

Interference  with  the  prostate,  either  alone  or  in  conjunction  with  the 
other  genital  organs,  seems  to  be  generally  regarded  as  a  serious  matter 
find  productive  of  bad  results.  Enucleation  is  exceedingly  difficult  or 
impossible  owing  to  adhesions.  Incision  and  drainage  of  an  abscess 
gives  only  temporary  relief,  and  is  generally  productive  of  a  permanent 
fistula.  I  agree  with  Lapeyre42  that  operations  upon  the  prostate  are 
inadvisable;  n  ild  affections  will  heal  after  the  removal  of  the  epi- 
didymis,  and  extensive  lesions  had  best  be  let  alone.  In  my  opinion, 
the  same  may  be  said  of  the  seminal  vesicle. 

The  treatment  of  tuberculous  stricture  of  the  urethra  had  best  be 
conservative.  Dilatation,  under  the  influence  of  a  local  anesthetic  in 
the  urethra  (a  5  per  cent,  solution  of  alypin  is  very  satisfactory),  is 
usually  successful ;  in  other  cases,  internal  urethrotomy  may  be  neces- 
sary, but  should  be  done  only  on  strictures  anterior  to  the  bulbous 
urethra.  External  urethrotomy  should  be  avoided  on  account  of  the 
danger  of  establishing  a  permanent  urethral  fistula.  Whichever  is  done, 
dilatation  or  urethrotomy,  a  tuberculous  stricture  will  close  down  rap- 
idly and  require  constant  attention. 

Many  authorities  are  now  agreed  that  tuberculin  is  a  valuable  adjunct 
in  the  treatment  of  genital  tuberculosis,  especially  after  operation.  \\re 
have  used  it  for  a  number  of  years  in  the  after-treatment  of  both 
genital  and  urinary  tuberculosis.  Our  opinion  of  it  and  the  details 
of  its  use  have  been  set  forth  by  O'Xeil  and  Hawes.48 

"Tuberculin  injections  are  used  in  conjunction  with  other  measures, 
but  in  few  if  any  cases  would  we  be  willing  to  attribute  to  tuberculin, 
all  or  nearly  all  of  the  improvement.  In  some  of  the  genito-urinary 
cases  it  has  seemed  as  if  tuberculin  was  an  important  factor  in  the 
treatment;  in  the  great  majority  of  cases,  however,  while  a  factor,  it  is 
by  no  means  the  most  important  one  in  producing  results.  The  tuber- 
culin used  is  a  bouillon  filtrate  (or  bacillary  emulsion)  supplied  by  Dr. 
E.  R.  Baldwin  of  the  Saranac  Lake  Laboratory.*  It  is  administered 
once  a  week  according  to  the  rules  of  Trudeau,  the  initial  dose  being 
from  0.0001  mg.  to  0.0005  mg.,  rarely  0.001  mg.  This  is  gradually 
increased  to  50  to  100  nigs.  The  increase  in  dosage  is  gauged  by  careful 
observation  of  clinical  signs  of  reaction,  local,  focal  or  constitutional. 
Constitutional  reactions  have  been  rare  and  no  untoward  results  have 
followed  such  as  have  occurred.  Occasionally  benefit  has  seemed  to 
follow  a  mild  constitutional  disturbance.  It  is  the  aim,  however,  to 
avoid  all  such,  and  as  a  rule  it  has  been  possible  to  carry  patients  up 
to  large  amounts  without  discomfort.  ...  As  the  local  and  gen- 
eral conditions  improve,  the  patients  are  allowed  to  come  once  in  two 
weeks  and  when  the  process  is  arrested,  to  report  once  a  month  or  once 
in  two  months." 

As  I  have  stated  elsewhere,6  "it  all  comes  down  to  a  question  of 

*  It  may  also  be  obtained  from  the  H.  M.  Alexander  Co.,  Marietta,  Pa.  Solutions 
suitable  for  immediate  use,  without  further  dilution,  may  be  had  by  special  arrangement. 


532  GENITAL   TUBERCULOSIS 

immunity.  Once  fortified  in  this  manner  a  patient  can  ward  off  an 
onslaught  of  the  tubercle  bacillus,  which,  under  other  circumstances, 
would  get  the  upper  hand  in  a  short  time.  While  we  have  all  seen 
patients  with  surgical  tuberculosis,  who  have  fought  single-handed  a 
winning  battle  for  many  years,  we  should  not  hesitate  to  bring  to  their 
relief  the  best  of  hygienic  treatment,  the  regular  and  continuous 
administration  of  sandalwood  oil,  and  the  use  of  tuberculin.  .  .  . 
Under  these  conditions  whatever  natural  immunity  the  patient  may 
possess,  or  has  acquired,  will  be  raised  to  the  highest  possible  point,  a 
factor  which  I  believe  will  give  the  victims  of  this  disease  a  better 
outlook  in  the  future  than  they  have  had  in  the  past." 

BIBLIOGRAPHY. 

1.  Asch:  Zeit.  f.  Urol.,  1909. 

2.  Balliano:  Beit,  zur  Klinik  der  Tuberkulose,   1912. 

3.  Barney:  Am.  Jour.  Urol.,  1911;  Boston  Med.  and  Surg.  Jour.,  clxviii,  1913. 

4.  Barney:  Boston  Med.  and  Surg.  Jour.,  1912,  clxvi,  No.  11. 

5.  Barney:  Jour.  Am.  Med.  Assn.,  December  31,  1914. 
6    Barney:  Surg.,  Gynec.  and  Obst.,  March,  1914. 
7.  Baudet:  Rev.  de  Chir.,  1901,  i. 


8.  Baumgarten 

9.  Baumgarten 
10.  Baumgarten 


Arch.  f.  klin.  Chir.,  1901,  Ixiii. 

Langenbeck's  Arch.,  1901,  Bd.  Ixiii,  H.  4. 

Verhandl.    der   deutsch.    path.    Gesellschaft,    1905;    Arbeiten    aus 


dem  path.-anatom.  Inst.  zu  Tubingen,  1906,  v. 

11.  Belfield:  Jour.  Am.  Med.  Assn.,  October  19,  1912. 

12.  Berger:  Arch.  f.  klin.  Chir.,  1902,  Ixviii. 

13.  Brown:  Jour.  Am.  Med.  Assn.,  1915,  Ixiv,  No.  11. 

14.  Buday:  Virchows    Archiv,    1906. 

15.  Cabot  and  Barney:  Jour.  Am.  Med.  Assn.,  1913,  Ixi. 

16.  Cholzoff:  Folia  Urologica,  1908-09,  iii. 

17.  Crandon:  Boston  Med.  and  Surg.  Jour.,  1902,  cxlvii. 

18.  Davids:  Inaug.  Dissert.,  Gottingen,  1898. 

19.  Delli  Santi:  Riforma  Medica,  1903,  No.  34. 

20.  Dreyer:  Inaug.  Dissert.,  Gottingen,  1891. 

21.  Ferron:  Jour.  d'Urol.,  June  15,  1913. 

22.  Gotzl:  Folia  Urologica,  1912-13,  vii. 

23.  Guisy:  Ann.  des  Mai.  des  Org.  Cenito-urinaires,  1906. 

24.  Haas:  Beit,  zur  klin.  Chir.,  1901,  xxx. 

25.  Halle  and  Motz:  Ann.  des  Mai.  des  Org.  Genito-urinaires,  1903. 

26.  Hesse:  Cent.  f.  der  Grenzgebiete  der  Med.  und  Chir.,  1913,  xvii. 

27.  Heyn:  Virchows  Archiv,  1901. 

28.  Huet:  Centralbl.  f.  Bakt.,  1909,  Iii. 

29.  Hueter:  Ziegler's  Beit.,  1904. 

30.  Jannsen:  Sammlung  klin.  Vortrage,  1910-11. 

31.  Kantorowicz:  Inaug.  Dissert.,  Berlin,  1893. 

32.  Kappis:  Inaug.  Diss.,  Tubingen,   1905. 

33.  Keyes:  Ann.  Surg.,  June,  1907. 

34.  Kocher:  Deut.  Chir.,  1887,  Bd.  1. 

35.  Kocher:  Deut.  Chir.,  1887,  1. 

36.  Konig:  Deut.  Zeit.  f.  Chir.,  1898,  xlvii. 

37.  Kowalewsky:  Jahresb.  der  ges.  Medizin,  1907. 

38.  Kraemer:  Wien.  med.  Wchiischr.,  1900,  1;  Deut.  Zeit.  f.  Chir.,  1903,  Ixix. 

39.  Kraemer:  Ziegler's  Beit.,  1904. 

40.  Krzywicki:  Ziegler's  Beitr.,  1888,  iii. 

41.  Kuhn:  Jahresb.  der  ges.  Med.,  1906. 

42.  Lapeyre:  Arch.   gen.   de   chir.,    1912,    viii. 

43.  Le  Dentu:  Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1912,  xxxviii. 

44.  Lelongt:  These  de  Paris,  1911. 

45.  Lowenstein:  Deut.  med.  Wchnschr.,  1913,  xxxix. 

46.  Marinesco:  Jour.  d'Urol.,  1912,  i. 

47.  Meyer:  Virchows  Archiv,  1895. 


BIBLIOGRAPHY  533 

48.  O'Neil  and  Hawes:  Tr.  Am.  Assn.  Genito-Urin.  Surg.,  1913,  viii. 

49.  Oppenheim  and  Low:  Vichows  Archiv,  1905,  clxxxii. 

50.  Paladino-Blandini:  Ann.  des  nial.  des  Org.  Genito-urinaires,  1900. 

51.  Pinaud:  Seifert,  Dermatologische  Studien,  1903-1910. 

52.  Reclus:  These  de  Paris,  1876. 

53.  Roily:  Jahresb.  f.  ges.  Med.,  1909. 

54.  Samuel:  Wiener  klin.  Rundschau,   1911,   No.  47. 

55.  Sangiorgi:  Cent.  f.  allg.  Path,  und  path.  Anat.,  1909,  xx. 

56.  Sawamura:  Deut.  Zeit.  f.  Chir.,  1909-10,  ciii. 

57.  Sawamura:   Folia    Urologica,    1910,    Bd.    iv. 

58.  Saxtorph:  Cong.  Internat.  de  Chir.  Urin.,  1900. 

59.  Schmidt:  Inaug.  Dissert.,  Tubingen,  1896. 

60.  Simon:   Dcut.  Gesellschaft  f.  Chir.,  1901,  xxx. 

61.  Spano:  Rev.  de  la  Tuberculose,  December  31,  1903. 

62.  Sugimura:  Arbeitcn  auf  dem  Gebiete  der  path.  Anat.  und  Bakt.,  1912,  viii. 

63.  Testut:  Traite  d'Anatomie  Humaine,  1897. 

64.  Teutschlander:  Beitr.  zur  Klinik  der  Tuberkulose,  1905. 

65.  Teutschlander:  Beitr.  zur  Klinik  der  Tuberkulose,  1906. 

66.  Tylinski:    Deut.  Zeit.  f.  Chir.,  1911,  ex. 

67.  Uchimura:  Sei-I-Kwai  Med.  Jour.,   1914,  xxxiii. 

68.  Vignard  and  Thevenot:  Ann.  de  Med.  et  Chir.  Infantiles,  1911,  xv. 

69.  von  Bruns:  Deut.  Gesellschaft  f.  Chir.,  1901,  xxx. 

70.  Walker,  George:  Johns  Hopkins  Hosp.  Rep.,  1911. 

71.  Walker,  K.  M.:  Lancet,  1913,  i. 

72.  Walker  and  Hawes:  St.  Bartholomew's  Hosp.  Rep.,  1911,  xlvii. 

73.  Whiteside:  Tr.  Am.  Assn.  Genito-urinary  Surg.,  1914,  ix. 

74.  Wyssokowicz:  Zeit.  f.  Hyg.  und  Infectionskrankheiten,   1908. 


CHAPTER   XVII. 
TOIORS  OF  THE  TESTICLE. 

BY  EDWIN  BEER,  M.D. 

Frequency. — Tumors  arising  in  the  testis  are  not  frequent.  Accord- 
ing to  Howard,1  in  110,00')  patients  there  were  65*  malignant  testicular 
neoplasms.  Other  statistics  show  a  higher  incidence,  1  to  every  1000 
males. 

Etiology. — Neoplasms  are  thought  to  be  relatively  more  common  in 
undescended  testifies  than  in  normally  placed  organs.  In  Howard's 
110,000  patients  (vide  supra),  out  of  57  cases  of  malignant  disease 
9  (15.7  per  cent.)  occurred  in  undescended  testicles,  which  is  out  of  all 
proportion  to  the  relation  between  normal  and  abnormally  placed 
testicles.  Odiorne  and  Simmons11  similarly  found  in  54  malignant 
cases  (>  in  undescended  testicles;  4  of  these  were  abdominal  and  2 
inguinal.  Infra-abdominal  testicular  retention  has  been  thought  to  be 
more  likely  to  lead  to  malignancy  than  the  facts  seem  to  warrant.  In 
Bulkley's3  statistical  study  he  concludes  that  malignant  disease  of  the 
abdominal  testicle  is  relatively  rare  (1  to  (50,000  patients).  Of  the 
malignant  non-descended  testicles,  25  per  cent,  are  abdominal.  "  About 
1  of  each  75  abdominally  retained  testes  will  become  malignant." 

Train/ia  has  frequently  been  claimed  to  lead  to  neoplasms.  For 
instance,  of  late  Sekaguchi  reported  32  cases  and  in  4  he  thought  the 
tumor  followed  trauma.  T.  Miyata12  found  in  50  per  cent,  of  a  series 
of  20  cases  a  similar  etiological  factor.  Undescended  inguinal  testicles 
are  peculiarly  exposed  to  repeated  traumata  and  here  this  may  prove  an 
etiological  factor,  just  as  in  other  parts  of  the  body  chronic  irritation 
seems  to  be  of  importance.  It  is,  however,  more  than  doubtful  whether 
single  injuries  do  more  than  call  attention  to  previously  unnoticed 
developments.  Metastases  in  the  testis  are  very  infrequent. 

Pathology. — As  Adami1  says,  the  variety  of  forms  of  testicular  neo- 
plasm is  bewildering.  There  is  probably  no  field  of  pathology  in  which 
more  divergent  views  have  been  and  still  are  current.  On  the  one  hand, 
we  find  described  all  varieties  of  neoplasms,  and  on  the  other,  we  find 
almost  all  gathered  together  as  teratomata.  Ziegler  (1902)  describes 
adenoma,  adenocystoma,  adenomatous  teratoma,  chondro-adenoma, 
chondrocystoma,  adenosarcoma,  carcinoma,  chondrocarcinoma,  enchon- 
droma,  fibroma,  myomastriocellulare,  myxoma,  osteoma,  sarcoma, 
lymphosarcoma,  alveolar  sarcoma,  endothelioma,  and  dermoids.  E. 
Kaufman11  (1911)  describes  a  number  of  rare  types,  such  as  fibroma, 
lipoma,  myxoma,  myoma,  chondroma,  osteoma,  and  then  the  more 

*  Fifty-seven  verified  microscopically  by  Howard. 
(534; 


PATHOLOGY  535 

common  types,  such  as  sarcoma,  adenoma,  adenocystoma,  caTcinoma, 
dermoid  cysts,  teratoma,  and  chorio-epithelioma.*  At  the  opposite  ex- 
treme, Ewing6  concludes  that  the  "  commonest  tumor  of  the  testis  is  an 
embryonal  carcinoma,  alveolar  or  diffuse,  with  polyhedral  or  rounded 
cells  and  often  with  lymphoid  stroma.  These  tumors  are  probably 
one-sided  developments  of  teratomata."  Wilson  finds  that  all  of  19 
tumors  that  could  be  studied  histologically  in  detail  proved  to  be 
teratomata.  Fibroma,  leiomyoma,  lymphosarcoma,  spindle-celled  sar- 
coma, adenoma,  lowing  admits  as  exceptional  or  unique  occurrences. 

Of  late  years  the  tendency  toward  a  teratomatous  explanation  has 
become  stronger  and  stronger.  More  careful  study  of  tumors  that  were 
originally  classified  as  sarcoma  or  carcinoma,  etc.,  have  demonstrated  a 
tridermal  constitution  (Wilms) .  The  Marchand-Bonnet  explanation  of 
the  origin  of  these  neoplasms  as  well  as  of  ovarian  teratomata,  from 
isolated  blast omeres  has  gradually  obtained  more  adherents,  especially 
since  it  has  been  shown  (Wilms,  Pick)  that  one  element  may  dominate 
the  histological  picture.  Further  studies  will  decide  whether  pure 
carcinoma  (seminoma)  derived  from  seminiferous  tubule  epithelium  is 
an  entity  or  not.  Chorio-epithelioma  (Schlagenhaufer)  f  J  invading  the 
veins,  as  in  the  female,  is  a  rare  but  well-recognized  type. 

The  complexity  of  the  microscopic  picture  of  most  of  these  tumors 
can  be  readily  grasped  when  one  bears  in  mind  that  any  type  of  tissue 
(tridermal)  may  be  represented.  On  the  other  hand,  there  is  some  uni- 
formity in  the  gross  appearance  and  in  the  method  of  progression 
exhibited  by  these  neoplasms  which  are  usually  malignant. If  They  usu- 
ally commence  in  the  body  of  the  testis  near  the  epididymis,  perhaps 
occasionally  in  the  latter.5  At  this  early  stage  one  rarely  sees  them 
clinically.  As  they  grow  the  albuginea  stretches  and  the  whole  organ 
seems  to  enlarge  more  or  less  symmetrically,  though  on  cross-section 
one  may  see  that  the  growth  has  compressed  the  adjacent  testicular 
tissue.  On  cross-section  they  may  be  solid  or  in  part  cystic.  Areas  of 
necrosis  are  not  rare.  In  some  cases  fluid  accumulates  in  the  tunica 
vaginalis,  but  usually  the  amount  of  fluid  is  small.  In  some  cases  this 
may  become  bloody.  Rarely  the  growth  perforates  the  scrotal  skin 
and  produces  a  fungus.  Extension  is  usually  by  the  lymphatics,  though 
some  tumors  behave  like  the  chorio-epitheliomata  which  rapidly  spread 
through  the  veins.  The  retroperitoneal  (lumbar  and  aortic)  glands  are 
first  involved.  The  local  inguinal  glands  may  become  involved.10 
Metastases  occur  in  the  bronchial  glands,  lungs,  liver,  spleen,  intestines, 
kidneys,  spinal  cord,  etc. 

In  intra-abdominal  testis  such  malignant  tumors  may  grow  into 

*  Chevassu,4  in  128  cases,  found  59  seminal  epitheliomata  (seminoma)  and  62  embryo- 
mata  (These  de  Paris,  1906). 

t  W.  Risel  from  Marchand's  Laboratory,  derives  these  growths  from  fetal  ectoderm 
just  as  in  similar  growths  in  females. 

}  According  to  Sternberg,16  these  are  perithelial  sarcomata. 

1[  In  these  pages  testicular  neoplasms  are  discussed  almost  entirely  from  this  stand- 
point in  the  interest  of  the  patient.  Almost  all  these  tumors  are  clinically  malignant, 
though  occasionally  benign  growths  that  do  not  produce  metastases  occur. 


Tl'MdRS  OF   THE    TESTICLE 


adjacent  structures,  so  that  their  removal  becomes  impossible.  Ad- 
jacent viscera,  vessels  and  nerves  may  become  involved  by  continuity. 

Clinical  Picture  and  Diagnosis.  —  The  clinical  picture  presented  by 
these  growths  is  confusing.  Some  begin  to  grow  in  early  life  and  grow 
very  gradually  and  slowly.  They  present  themselves  as  rather  firm  and 
uniform  testicular  enlargements.  Others  are  seen  in  more  advanced 
life  and  are  characterized  by  the  more  rapid  development  of  very  hard 
nodules  in  the  testicle.  Others,  again,  develop  in  children  and  young 
men,  grow  rapidly  and  cause  uniform  firm,  elastic  enlargement  of  the 
testicle.  Between  the  ages  of  eighteen  and  forty-five  neoplasms  are 
most  common.*  All  are  characterized  by  producing  a  marked  increase 
in  weight  of  the  involved  organ.  Pain  at  first  is  absent  but  later  may 
be  very  severe.  Local  tenderness  may  be  very  slight  and  testicular 
sensation  is  usually  preserved.  A  hydrocele  may  obscure  the  under- 
lying trouble. 

A^  there  is  nothing  absolutely  typical  of  these  growths,  their  recog- 
nition often  depends  upon  the  exclusion  of  other  testicular  diseases, 
especially  of  syphilis  and  of  tuberculosis,  f  Syphilis  usually  produces 
irregular  testicular  tumors  which  are  very  heavy  and  often  not  ten- 
der. The  presence  of  a  positive  Wassermann  and  rapid  diminution 
in  size  following  antisyphilitic  therapy  will  often  clear  up  the  diagnosis. 
One  must,  however,  always  bear  in  mind  that  constitutional  syphilis  may 
complicate  a  testicular  neoplasm  and  not  delay  the  diagnosis  more  than 
a  few  weeks  with  antisyphilitic  therapy.  It  is  preferable  to  occasionally 
remove  a  syphilitic  testicle  than  to  delay  in  the  removal  of  a  malignant 
tumor.  Tuberculosis  rarely  mimics  a  new  growth.  It  usually  begins 
in  the  epididymis,  producing  a  finely  nodular  enlargement  and  involves 
the  testicle  later.  The  vas  becomes  beaded  and  enlarged.  The  skin 
may  become  adherent  and  fistulse  may  form  within  a  few  weeks.  By 
rectum  the  vesicle  of  the  same  side  as  well  as  the  prostate  may  show 
thickening  and  nodules.  Sometimes  one  may  be  in  doubt  and  in  these 
cases  old  tuberculin2  may  be  very  useful  in  establishing  a  diagnosis. 

When  the  testicle  is  situated  in  an  abnormal  position  the  symptoms 
may  be  much  more  marked,  e.  g.,  when  in  the  inguinal  canal,  or  they 
may  not  be  noticed  at  all  until  the  growth  presses  on  adjacent  struc- 
tures, e.  g.,  in  abdominally  retained  testis.  Here  pressure  on  veins  and 
edema,  or  pressure  on  nerves  producing  neuralgia  may  be  the  first 
symptoms. 

In  these  cases  the  history  of  the  patient  and  the  absence  of  testicle  in 
the  corresponding  half  of  the  scrotum  are  of  great  importance  in  arriving 
at  a  correct  diagnosis. 

In  all  cases  that  are  suspicious  of  neoplasm  the  testicle  should  be 
exposed  (vide  post)  and  the  diagnosis  made  by  inspection  if  it  cannot 
be  made  otherwise.  In  dealing  with  such  a  serious  condition  as  malig- 
nant disease  of  the  testicle  delay  and  hesitation  are  fatal. 

*  Chevassu*  found  seminomata  34  times  in  59  cases  between  the  ages  of  thirty-five 
and  forty-five  years;  embryomata  45  times  in  61  cases  between  eighteen  and  forty  years. 
t  A  thickened  tunica  vaginalis  or  a  hematocele  may  simulate  a  neoplasm. 


PROGNOSIS  537 

Prognosis. — It  is  well  recognized  that  the  outlook  for  patients  suffer- 
ing from  tumors  of  the  testicle  is  not  good.  Whether  the  results  are 
going  to  improve  with  more  extensive  removal  of  the  retroperitoneal 
glands,15  just  as  more  extensive  operations  in  other  parts  have  given 
better  results,  one  cannot  say  as  yet.  With  the  older  procedure  of 
simple  castration,  Nicholson13  reports  on  18  patients  that  were  followed; 
12  of  these  died  within  one  year  of  the  operation,  and  (i  were  alive  one  to 
five  years  after  operation.  In  Howard's9  series  of  57,  only  21  patients 
could  not  be  followed.  Of  the  remaining  30,  8  were  alive  some  time 
after  operation,  but  only  2  were  definitely  known  to  be  alive  three  years 
after  operation;  27  of  the  36  had  recurrences,  2  local  and  18  glandular 
and  distant.  Chevassu  thinks  the  prognosis  is  perhaps  as  bad  as  in 
malignancy  in  any  organ,  and  estimates  that  only  19  per  cent,  live  to 
the  four-year  limit  free  from  recurrence.* 

Hinman,8  reviewing  the  cases  examined  at  Johns  Hopkins  and  in  local 
laboratories,  found  that  only  4  patients  out  of  24  were  alive.  Of  the  9 
teratomatous  cases,  all  except  1  patient  had  died,  and  he  had  been 
operated  only  sixteen  months  before.  Of  9  round-cell  carcinoma  cases, 
2  patients  were  alive  twelve  to  thirteen  years. 

On  the  other  hand,  Codman  and  Sheldon,5  in  an  analysis  of  56 
operated  cases,  come  to  the  conclusion  that  the  results  of  operations 
are  more  than  twice  (41  per  cent,  cures)  as  good  as  those  just  reported, 
and  if  the  operation  is  done  before  palpable  metastases  have  developed, 
52  per  cent,  will  be  cured. 

These  more  favorable  data  are  open  to  criticism,  as  the  cases  had  not 
been  followed  long  enough.  For  instance,  of  the  13  patients  who  were 
alive,  the  period  since  operation  wras  from  two  to  twenty-eight  years. 
Moreover,  of  the  10  other  patients  (making  23  out  of  56,  or  41  per  cent.) 
1  had  died  seven  months  after  operation  following  burns,  and  another 
three  years  after  operation  following  an  injury.  Whether  autopsies 
had  proved  that  these  were  free  from  cancer  is  not  stated.  Even 
rhevassu's  four-year  limit  does  not  seem  to  be  sufficient,  as  recurrences 
have  been  noted  later. 

A  review  of  the  literature  demonstrates  that  the  more  cellular  type  of 
neoplasm  produced  secondary  deposits  later  than  the  cases  with  more 
distinct  teratomatous  arrangement.  In  other  words,  the  prognosis  in 
the  latter  type  seems  more  unfavorable  than  in  the  former,  as  it  spreads 
more  rapidly  through  the  lymphatics  into  the  thoracic  duct  and  thence 
into  the  blood  stream. 

The  extensive  operation  advocated  more  and  more  during  the  last 
decade  attempts  to  remove  en  bloc  all  the  lymphatic  bearing  retroperi- 
toneal fatf,  starting  well  up  (Fig.  227)  near  the  renal  vein  and  coming 
down  to  the  iliac  fossa  and  spermatic  cord  and  testicle.  Hinman  has 
collected  some  46  cases  (mortality  11  per  cent.)  in  which  this  operation 
was  more  or  less  thoroughly  carried  out,  and  found  that  16  (41  per  cent.) 

*  Recurrences  after  four  years  have  been  reported. 

t  Through  the  courtesy  of  Dr.  Hinman,  the  excellent  plates  used  in  his  paper,  referred 
to  above,  are  here  reproduced. 


538  TUMORS  OF   THE   TESTICLE 

died  of  cancer  within  one  to  four  years.  This  series  throws  no  direct 
light  upon  the  end-results  of  this  extensive  operation,  as  compared  with 
those  obtained  by  simple  castration,  though  indirectly  these  cases 
demonstrate  very  clearly  that  the  glandular  metastases  were  present  in 
50  per  cent,  of  the  cases  and  that  simple  castration  under  such  condi- 
tions would  have  been  useless.  If  any  of  these  cases  are  saved,  it  will  be 
due  to  the  radical  procedure.  Glandular  involvement  is  difficult  to 
recognize  before  operation  even  though  it  is  so  extensive  as  to  preclude 
radical  removal.  In  this  series  such  was  the  case  in  11  patients. 


FKJ.  227. — Primary  lymph  nodes  of  the  testicles.     (From  Spalteholtz  and  dissections.) 

Treatment. — In  view  of  what  has  just  been  said  concerning  the  diffi- 
culty in  diagnosis  and  the  bad  outlook,  the  interest  of  the  patient 
demands  that  all  enlargements  of  the  testicle  that  are  not  frankly  non- 
neoplastic  should  be  exposed  and  their  exact  nature  determined  by 
inspection  and  microscopic  examination  in  the  operating  room.  This 
procedure  can  be  carried  out  with  perfect  safety  by  exposing  the  cord 
at  the  internal  ring,  after  incising  the  anterior  wall  of  the  inguinal  canal 
and  then  throwing  a  rubber  ligature  about  the  cord  so  that  in  the 
manipulations  to  liberate  the  testis  from  the  scrotum  no  tumor  cells  are 
forced  into  the  general  circulation.  After  delivering  the  enlarged 
testis,  inspection  may  demonstrate  that  the  enlargement  is  neoplastic. 
If  in  doubt,  after  carefully  protecting  the  wound,  an  incision  should  be 
made  and  a  piece  of  the  suspicious  tissue  immediately  examined  under 
the  microscope.  The  peculiar  structure  of  these  growths  can  be  readily 


TREATMENT 


539 


FIG.  228. — Peritoneum  stripped  bark  showing  lymph  area  to  be  removed. 


FIG.  229. — Lumbar  and  iliac  fossae  stripped  clean  of  glands  and  fascia  with  the 
spermatic  vessels  down  to  the  inguinal  ring.  Vas  deferens  entering  pelvis  at  point  where 
it  is  divided. 


540  TUMORS  OF  THE  TESTICLE 

• 

identified  and  then  the  castration  completed.*  By  enlarging  the  orig- 
inal incision  from  the  internal  ring  toward  the  lumbar  region,  as  shown 
in  the  accompanying  illustrations  (Figs.  228  and  229)  borrowed  from 
Hinman's  paper,  a  retroperitoneal  exposure  of  the  gland-bearing  area  is 
obtained.  This  area  should  be  excised  from  above  downward,  begin- 
ning near  the  renal  pedicle.  Even  though  at  present  the  mortality  of 
this  operation  is  much  higher  than  that  of  simple  castration,  experience 
has  shown  that  such  is  the  case  with  all  new  operations.  The  writer  feels 
confident  that  during  the  next  decade  the  mortality  from  this  extensive 
operation  will  be  markedly  reduced.  Moreover,  he  believes  that  we 
are  justified  in  expecting  better  end-results  when  the  gland-bearing 
area  is  removed.  Operations  for  malignant  disease  in  other  parts 
surely  support  this  position.  The  fight  against  cancer  cannot  be  half- 
hearted: the  surgeon  must  strike  hard  or  fail  in  his  duty. 

Recurrences  and  Inoperable  Cases;  Postoperative  Prophylaxis. — Local 
recurrences  may  be  amenable  to  excision,  whereas  distant  deposits  are 
probably  always  only  a  part  of  multiple  metastases  and  therefore  not 
operable.  In  these  cases,  as  well  as  in  the  inoperable  cases,  an  attempt 
should  be  made  to  control  the  disease  with  Coley's  fluid,  which, 
according  to  his  recent  report,  has  given  some  encouraging  results. 
Coley  and  others  advise  the  prophylactic  administration  of  this  fluid, 
after  removal  of  the  original  trouble,  to  prevent  recurrence.  It  is 
naturally  impossible  to  estimate  its  efficacy  in  this  field. 


BIBLIOGRAPHY. 

1.  Adami:  Text-book  of  Pathology,   1914,  2d  edition. 

2.  Beer:  Med.  Rec.,  October,  1913. 

3.  Bulkley:  Surg.,  Gynec.  and  Obst.,  1913. 

4.  Chevassu:  These  de  Paris,  1906. 

5.  Codman  and  Sheldon:  Boston  Med.  and  Surg.  Jour.,  February,  1914. 

6.  Ewing:  Surg.,  Gynec.  and  Obst.,  1911. 

7.  Gregoire:  Jour.  Am.  Med.  Assn.,  1914. 

8.  Hinman:  Jour.  Am.  Med.  Assn.,  1914. 

9.  Howard:  Practitioner,  December,  1907. 

10.  Howard  and  Miyata:  Langenbeck's  Archiv,  ci. 

11.  Kaufman:  Lehrb.  path.  Anat. 

12.  Miyata:  Langenbeck  Archiv,  ci. 

13.  Nichobon:  Guy's  Hosp.  Rep.,  Ixi. 

14.  Odiorne  and  Simmons:  Ann.  Surg.,  1904. 

15.  Roberts:  Ann.  Surg.,  1902. 

16.  Sternberg:  Zeit.  f.  Heilk.,  1905,  xxvi. 

*  If  no  neoplasm  is  present  the  testis  is  sewed  up  and  returned  to  the  scrotum  after 
removal  of  the  hemostatic  ligature  of  the  cord. 


SECTION  IV. 

THE  PROSTATE  AND  SEMINAL 
VESICLES. 


CHAPTER  XVIII. 

ANATOMY   AND   PHYSIOLOGY   OF  THE   PROSTATE   AND 
SEMINAL  VESICLES. 

BY  WM.  C.  QUINBY,  M.D. 

PROSTATE. 

Definition.— The  prostate  is  the  most  important  of  the  male  accessory 
genital  glands.  It  is  a  musculoglandular  organ  lying  between  the 
outlet  of  the  urinary  bladder  and  the  triangular  ligament,  and  enclosing 
within  its  substance  the  first,  or  prostatic,  portion  of  the  urethra  and 
ejaculatory  ducts.  It  shows  a  somewhat  different  morphology  at  the 
three  periods  of  life:  infancy,  puberty  and  old  age. 

Embryology. — For  a  clear  understanding  of  the  anatomy  of  the  pros- 
tate a  knowledge  of  its  embryological  development  is  most  important. 
Indeed,  it  is  only  since  the  relatively  recent  studies  on  the  formation  of 
this  organ,  by  Weski,  Pallin,9  Porosz,12  and  Lowsley,7  that  there  has 
existed  any  unanimity  of  opinion  among  anatomists  and  surgeons  as  to 
the  relative  importance  and  significance  of  the  various  lobes  which 
together  constitute  the  gland.* 

At  about  the  third  month  of  intra-uterine  development  the  walls  of 
the  urethra,  just  below  the  bladder  proper,  show  two  small  longitudinal 
depressions — the  so-called  prostatic  furrows;  and  at  the  same  time 
there  are  seen  clumps  of  cells  lying  in  the  wall  of  the  urethra,  which  in  a 
short  time,  by  a  process  of  budding,  become  differentiated  into  glan- 
dular masses  and  tubules.  These  glandular  elements  penetrate  the 
surrounding  muscular  and  embryonic  connective  tissue  in  five  distinct 
groups.  One  group  takes  its  origin  from  the  posterior  midline  of  the 
urethra,  just  above  the  openings  of  the  ejaculatory  ducts;  one  on  either 
side  from  each  prostatic  furrow  and  lateral  urethral  wall;  one  from  a 
point  just  below  the  ejaculatory  ducts,  and  one  from  the  anterior  wall  of 

*  Of  these  studies  by  far  the  most  important  are  those  of  Lowsley,  to  whom  the 
writer  is  indebted  for  many  of  the  points  brought  forward  in  this  present  account. 

(541) 


Ureter, 


/Sup  Wsical  art 
Ueiereniial 


Obturator  art- 
ext  Iliac  orl-^ 
Vas  defer*  ns 


Seminal  Vr 


FIG.  230. — Arteries  of  the  pelvis. 


FIG.  231. — Sagittal  view  of  a  wax  model  of  the  prostate  of  a  newborn  infant.  X  14. 
(From  Lowsley.)  Lat.,  anterior  branches  of  lateral  lobes;  P.L.,  posterior  lobe;  E.J., 
ejaculatory  duct;  S.V.,  seminal  vesicle;  A.L.,  anterior  lobe  tubule;  U.,  urethra;  U.P., 
utriculus  prostaticus;  A.G.,  subcervical  glands  of  Albarran;  M.L.,  middle  lobe  tubules; 
L.Ur.,  left  ureter;  BL,  bladder;  P.GL,  prostate  gland. 


PLATE  VI 


revitoneuw  of 
Douglas^  pouch 


Denonvillier  s     fascia  ; 
over    posterior  surface 
of  prostate 


Dissection  of  Prostate  and  Seminal  Vesicles  from  Behind,  to  Show  Fascia  of  Denonvilliers.  r 
the  Location  of  the  Peritoneum  bet-ween  the  Two  Ampullae  of  Vasa  Deferentia.  The  Saci 
Coccyx  have  been  Removed. 


PROSTATE  543 

the  urethra,  opposite  the  others.  These  form  respectively  the  middle, 
two  lateral,  posterior  and  anterior  lobe  glands.  The  middle  lobe 
tubules  grow  posteriorly  between  the  ejaculatory  ducts  and  the  urethra. 
Those  of  the  two  lateral  lobes  also  grow  backward,  and  later  form 
almost  the  whole  of  the  base  of  the  organ.  They  are  not  separated  from 
the  middle  lobe  by  an  intraglandular  capsule.  The  tubules  of  the  pos- 
terior lobe,  arising  below  the  ejaculatory  ducts,  grow  backward  behind 
these  structures  and  are  definitely  separated  from  the  lateral  lobes  by  a 
fibrous  intraglandular  partition.  The  anterior-  lobe  tubules,  few  in 
number  at  any  stage,  gradually  disappear,  until  at  birth  the  lobe  is 
represented  only  by  two  or  three  glandular  masses.  As  a  rule  this  lobe 
remains  insignificant,  or  it  may  even  disappear  entirely. 

Two  other  small  groups  of  glands  remain  to  be  mentioned — the  so- 
called  subcervical  and  subtrigonal.  The  first  of  these,  also  called  the 
group  of  Albarran — who  was  the  first  to  call  attention  to  its  importance 
— appears  to  be  constant  after  the  sixteenth  week,  while  the  subtrigonal 
group  makes  its  appearance  at  about  the  twentieth  week.  These  two 
glandular  masses  lie  closely  underneath  the  urethral  and  bladder 
mucosa  and  are  of  importance  only  because  of  their  ability  easily  to 
cause  obstruction  to  urinary  outflow  if  they  become  enlarged. 

The  ejaculatory  ducts  run  from  above  downward  and  forward 
obliquely  through  the  substance  of  the  prostate.  They  penetrate  the 
posterior  wall  of  the  prostatic  urethra  on  both  sides  of  the  utricle.  This 
structure,  the  remains  of  the  fused  Miillerian  ducts — an  analogue  of 
the  vagina  in  the  female — is  seen  as  a  blind  tube  running  for  a  shorter 
or  longer  distance  backward  into  the  substance  of  the  prostate.  The 
prominence  known  as  the  verumontanum,  on  the  posterior  wall  of  the 
urethra,  is  composed  of  the  utricle  with  the  ejaculatory  ducts  and  their 
envelopes. 

Gross  Anatomy. — The  shape  of  the  prostate  is  somewhat  that  of  a 
truncated  cone  with  apex  downward,  flattened  anteroposteriorly.  The 
average  dimensions  of  the  adult  gland  are  3.4  cm.  in  length,  4.4  cm.  in 
width,  and  2.6  cm.  in  thickness.  In  consistency  it  is  firmly  elastic. 
A  base,  apex,  anterior,  posterior,  and  two  lateral  surfaces  are  described. 

The  base  is  about  one-third  wider  laterally  than  anteroposteriorly. 
It  is  concave  and  is  directly  apposed  to  the  neck  of  the  bladder  and  to 
the  tips  of  the  seminal  vesicles.  It  is  pierced  by  the  urethra,  and  behind 
this  in  a  short  transverse  groove  by  the  entrance  points  of  the  two 
ejaculatory  ducts.  This  groove  divides  a  posterior  from  an  anterior 
area. 

The  apex  is  in  relation  with  the  triangular  ligament,  and  gradually 
becomes  merged  with  the  musculature  of  the  membranous  urethra. 

The  anterior  surface  of  the  gland,  flat  centrally  and  becoming  convex 
laterally,  looks  toward  the  symphysis  pubis,  from  which  it  is  separated 
by  cellular  tissue  and  by  the  liberal  plexus  of  veins  known  by  the  name 
of  Santorini. 

The  two  rounded  lateral  surfaces  are  closely  related  to  the  fibers  of 
the  levator  ani  muscle. 


544 


ANATOMY  AND  PHYSIOLOGY  OF  THE  PROSTATE 


The  posterior  surface  is  that  part  of  the  gland  which  can  be  palpated 
by  rectum.  It  is  broader  above  than  below,  and  in  the  midline  shows  a 
shallow  vertical  groove,  which  fades  out  toward  the  apex. 

On  the  posterior  wall  of  the  initial  portion  of  the  urethra  contained 
within  the  substance  of  the  prostate  is  seen  a  longitudinal  elevation, 
known  as  the  verumontanum.  On  both  sides  of  the  midline  of  this  are 
the  openings  of  the  ejaculatory  ducts,  while  in  the  middle  and  slightly 
above  there  occurs  the  slit-like  opening  of  the  utricle.  On  each  side 
and  below  the  verumontanum  are  seen  the  minute  openings  of  the 
prostatic  ducts. 

The  fascial  planes  surrounding  the  prostate  are  important,  although 
their  description,  as  found  in  various  anatomical  works  on  the  subject, 
differs  considerably.  This  seems  to  be  largely  due  to  the  well-known 
variations  in  development  of  the  levator  ani  muscle,  some  subjects 
showing  a  marked  increase  over  others  in  actual  muscular  fibers.  Ac- 
cordingly this  so-called  pelvic  diaphragm  has  no  absolutely  constant 


A/i tenor  lute 


MiddleZofa 


Utricle  arid 
fS        EfavaJatory  cturts 

Rstcrioi'lole 


FIG.  232.  —  The  prostate  in  cross- 
section.  Semidiagrammatic  camera- 
lucida  sketch. 


Internal  sphincter   Sv2>ce?mcat ytands 


[ftridd 


JyattrTatory  (fact 


FIG.  233. — The  prostate  in  sagittal 
section.  Semidiagrammatic  camera- 
lucida  sketch. 


amount  of  fibrous  expansion.  For  practical  purposes,  however,  the 
description  of  Denonvilliers,3  one  of  the  first  to  study  the  subject,  is 
sufficiently  accurate.  He  describes  a  puboprostatic  aponeurosw,  run- 
ning anteriorly  from  the  prostate  to  be  inserted  into  the  posterior  surface 
of  the  symphysis  pubis.  This  is  made  up  of  two  resistant  fibrous  layers 
on  each  side  of  the  middle  line,  which  sometimes  bear  the  name  of 
anterior  ligaments  of  the  bladder.  Between  these  there  is  a  space  of 
about  a  centimeter,  filled  by  a  delicate  but  quite  resistant  fibrous  tissue, 
pierced  by  numerous  holes,  through  which  run  the  dorsal  veins  of  the 
penis  to  reach  the  venous  plexus  at  the  neck  of  the  bladder. 

At  its  apex  the  prostate  is  supported  by  the  deep  layer  of  the  tri- 
angular ligament — the  trigonum  urogenitale  of  the  newer  nomenclature. 

On  each  side  is  found  the  so-called  lateral  aponeurosis  of  the  prostate. 
This  runs  from  the  descending  rami  of  the  pubis,  backward  to  join  the 
rectum;  and  by  it  the  prostate  is  separated  from  the  median  margins  of 
the  levator  ani  muscle.  It  is  closely  applied  to  the  sides  of  the  gland 


PROSTATE 


545 


and  is  united  to  it  by  the  cellular  tissue  containing  the  vesical  plexus 
of  veins. 

Behind  the  prostate,  separating  it  and  the  seminal  vesicles  from  the 
rectum,  there  is  a  transverse  aponeurosis,  known  commonly  as  the  fascia 
of  Denonvilliers,  but  which  he  calls  the  prostatoperitoneal  fascia.  He 
describes  this  layer  as  attached  below  and  anteriorly  to  the  tip  of  the 
prostate  and  triangular  ligament,  and  united  above  to  the  peritoneum, 
which  descends  between  the  bladder  and  the  rectum.  "  This  last  union 
is  as  marked  as  though  there  existed  continuity  of  tissue,  and  explains 
the  constancy  of  the  recto  vesical  cul-de-sac"  (Douglas's  fossa).  On 
each  side  this  fascia  is  attached  to  the  lateral  aponeurosis  described 
above.  By  its  posterior  surface  it  is  but  loosely  attached  to  the  rectum, 


FIG.  234. — Microscopic  section  of  prostate.     (  X  90.)      Branching  tubular  glands 
surrounded  by  smooth  muscle  fibers  and  connective  tissue. 


but  by  its  anterior  surface  it  is  quite  firmly  attached  to  the  seminal 
vesicles  and  to  the  true  capsule  of  the  prostate  gland.  The  texture  of 
this  membranous  layer  is  said  to  resemble  that  of  the  dartos.  It  is 
probably  a  fascia  resulting  from  the  obliteration  of  the  embryonic 
urorectal  septum. 

All  these  surrounding  prostatic  fasciae  make  up  the  prostatic  bed — 
the  loge  prostatique  of  the  French  writers— and  thus  serve  to  control  the 
direction  and  spread  of  suppurations  in  this  area.  The  posterior  fascia 
of  Denonvilliers  is  also  of  surgical  importance,  because  only  by  incising 
it  can  access  to  the  gland  be  had  in  the  operation  of  prostatectomy  by 
the  perinea!  method  of  Young. 

Besides  these  aponeuroses  described  above  the  prostate  has  a  true 
capsule  of  its  own  which  sends  prolongations  between  the  gland  lobes. 
M  u  i — 35 


546     ANATOMY  AND  PHYSIOLOGY  OF  THE  SEMINAL   VESICLES 

Bloodvessels,  Lymphatics  and  Nerves. — The  arteries  of  the  prostate 
are  branches  of  the  middle  hemorrhoidal,  of  the  inferior  vesical,  and  of 
the  internal  pudic.  The  veins  become  grouped  on  the  lateral  and 
anterior  surfaces  of  the  gland,  whence,  after  receiving  the  dorsal  veins 
of  the  penis,  they  eventually  empty  into  the  internal  iliacs.  The 
lymphatics  begin  about  the  gland  acini,  and  following  the  bloodvessels, 
drain  into  the  lymph  nodes  situated  on  the  hypogastric  and  iliac 
arteries.  They  are  very  numerous. 

The  nerves  of  the  prostate  are  derived  from  the  hypogastric  plexus 
of  the  sympathetic  and  also  from  the  anterior  roots  of  the  third  and 
fourth  sacrals.  These  show  many  ganglion  cells  and  variously  con- 
structed end-organs,  situated  chiefly  at  the  periphery  of  the  organ. 
From  the  elaborate  studies  of  Timofeew15  it  is  known  that  these  nerves 
are  medullated  as  well  as  non-medullated,  some  of  them  showing 
structures  resembling  the  Pacinian  corpuscles. 

Normal  Histology. — The  microscopic  picture  presented  by  the 
prostate  is  that  of  a  gland  of  the  compound  tubular  type.  Each  tubule 
is  surrounded  by  smooth  muscle  fibers  arranged  in  a  circular  fashion. 
Cylindrical  cells  with  a  basal  nucleus  line  these  tubules  in  a  single  layer. 
Occasionally  a  round  or  conical  cell  is  interposed  between  them.  The 
gland  ducts  are  quite  short  and  are  lined  by  a  single  layer  of  cuboidal 
cells,  which  gradually  become  identical  with  those  lining  the  urethra. 
The  smooth  muscle  surrounding  the  ducts  is  laid  down  in  a  longitudinal 
rather  than  circular  arrangement.  Beginning  just  above  the  veru- 
montanum  there  is  a  thick  mass  of  circular  smooth  muscle  fibers  laid 
down  in  a  ring  about  the  urethra.  These  form  the  internal  vesical 
sphincter.  Superiorly  the  fibers  are  continuous  with  the  middle  cir- 
cular coat  of  the  bladder.  Elastic  and  connective-tissue  fibers  are 
quite  numerous  throughout  the  gland,  and  an  occasional  area  of  lym- 
phoid  tissue  may  also  be  seen.  The  relative  amount  of  glandular  tissue 
to  muscular  and  supporting  structures  throughout  the  gland  is  about  as 
five  to  one  in  the  adult  prostate. 

SEMINAL  VESICLES. 

Definition. — The  seminal  vesicles  may  be  described  as  a  pair  of  con- 
voluted organs  lying  at  the  base  of  the  bladder,  between  it  and  the 
rectum,  and  converging  diagonally  toward  the  midline,  to  empty  into 
the  ejaculatory  ducts. 

Embryology. — Together  with  the  ejaculatory  ducts  the  seminal 
vesicles  appear  at  about  the  third  month  of  intra-uterine  life  as  lateral 
evaginations  of  the  Wolffian  duct.  At  the  fourth  month  the  vesicles 
begin  to  show  diverticula,  and  soon  after  this  assume  the  general  topog- 
raphy which  they  retain  until  puberty.  At  this  period  there  is  a 
marked  increase  in  the  size  of  these  organs,  as  well  as  an  addition  to  the 
number  and  diversity  of  their  diverticula. 

Gross  Anatomy. — The  adult  seminal  vesicle  shows  an  extreme  indi- 
vidual variation  in  size  as  well  as  in  the  number  and  kind  of  diverticula, 


SEMINAL  VESICLES 


547 


both  in  the  filled  and  empty  condition.     Its  cubic  volume  ranges  from 
one  to  three,  or  even  eleven,  cubic  centimeters  in  the  single  vesicle. 

The  average  length  is  from  forty-five 
to  fifty-five  millimeters;  the  average 
breadth  from  fifteen  to  twenty  milli- 
meters, and  the  average  thickness 
about  ten  millimeters.  Also  in  a 
single  individual,  one  vesicle  may 
be  of  different  size  and  shape  from 
its  fellow.  On  external  view  the 
vesicles  appear  as  somewhat  long 


FIG.  235. — Left  seminal  vesicle  and 
ampulla  of  vas  def  erens  in  section,  seen 
from  behind.  (FromEberth:  Mann- 
liche  Geschlechtsorgane.) 


FIG.  236. — Simple  convoluted  type  of  seminal 
vesicle.     (From  Picker;  Type  G.) 


organs,  flattened  anteroposteriorly  and  with  an  irregularly  corrugated 
surface,  which  has  been  likened  to  an  area  of  varicose  veins. 


FIG.  237. — Radiograph  of  injected  vesicles  and  vasa  deferentia.    (From  Picker;  Type  B.) 

The  inner  surface  of  the  vesicles  is  in  relation  with  the  vas  deferens 
and  its  ampulla,  with  which  the  vesicles  are  united  by  an  embracing 
fascia.  By  their  anterior  surfaces  they  are  closely  approximated  to  the 


548     ANATOMY  AND  PHYSIOLOGY  OF  THE  SEMINAL  VESICLES 

posterior  surface  of  the  bladder  wall.  The  upper  portion  of  their  outer 
surfaces  (upper  pole)  lies  against  the  ureter  just  at  the  beginning  of  its 
intravesicular  portion,  while  on  the  posterior  surface  the  vesicles  are 
separated  from  the  rectum  by  the  peritoneum  of  Douglas's  fossa  in  their 
upper  third,  and  by  the  fascia  of  Denonvilliers  in  their  lower  two-thirds. 


FIG.  238. — The  vesicles,  ampulla?  of  vasa  deferentia.  and  initial  portion  of  ejaculatory 
ducts  shown  by  the  corrosion  method.     (From  Pallin.) 

The  varieties  of  diverticula  have  been  carefully  studied  by  Pallin,9 
by  the  corrosion  method.     He  groups  the  vesicles  under  two  main 


FIG.  239. — Microscopic   section   of   seminal   vesicle.     ( X  90.)     Very   tortuous   glands 
filled  with  secretion  and  spermatozoa,  and  surrounded  by  a  thick  muscular  wall. 


headings;  (a)  those  with  slightly  convoluted  main  channels,  and  (6) 
those  with  the  main  channel  markedly  convoluted.  Under  each  divi- 
sion he  makes  two  subheadings,  according  as  the  diverticula  are  short 
and  uniformly  developed,  or  irregularly  developed  and  themselves  con- 
voluted. A  still  more  comprehensive  study  has  been  made  by  Picker,10 


PHYSIOLOGY  549 

who  injected  collargol  or  bismuth  paste  into  the  vesicles  in  150  subjects 
and  then  examined  them  by  radiographs.  He  divides  his  material  as 
follows : 

Vesicles  showing:  Per  cent. 

A.  Simple  straight  tubes 3.5 

B.  Thick,  twisted  coils  with  or  without  very  small  diverticula    .      .      .  15.0 

C.  Thin,  twisted  tubes  with  or  without  diverticula '.  15.0 

D.  Straight  or  twisted  main  channel  with  large  bulbous  diverticula       .  33.0 

E.  Short  main  channels;  large  branched,  irregular  accessory  channels   .  33.0 

F.  Varia 0.5 

Bloodvessels. — The  blood  supply  of  the  seminal  vesicles  is  large.  It  is 
derived  from  the  middle  hemorrhoidal  and  inferior  vesical  branches  of 
the  internal  iliac  artery.  The  main  point  of  entry  of  these  arteries  is  at 
the  upper  outer  border  of  each  vesicle.  This  fact  has  been  emphasized 
by  Barnett,  who  calls  it  the  vessel  pole,  and  who  advises  its  careful 
ligation  before  enucleation  of  the  organ.  The  veins  are  similar  to  the 
arteries.  The  nerves  are  derived  from  the  pelvic  plexus  of  the  auto- 
nomic  system  and  are  present  in  considerable  number.  The  lymphatics 
drain  into  the  glands  on  the  common  and  internal  iliac  vessels. 

Normal  Histology. — The  wall  of  the  seminal  vesicle  is  composed  of 
three  layers  of  smooth  muscle  fibers;  the  inner  and  outer  coats  running 
longitudinally,  while  the  middle  coat  is  circular.  These  enclose  many 
multilocular  cavities,  lined  by  high,  cylindrical  epithelium.  The  cavi- 
ties are  surrounded  by  many  elastic  tissue  fibers,  and  show  also  in  their 
periphery  numerous  sympathetic  nerve  ganglia. 

PHYSIOLOGY. 

The  prostate  is  best  examined  physiologically  from  three  aspects :  as 
a  secreting  gland,  as  a  muscular  organ,  and  as  an  organ  of  special 
function  represented  by  the  great  variety  of  nerve  structures  within 
its  substance. 

Secretion. — With  the  advent  of  puberty  the  prostate  and  seminal 
vesicles  assume  an  active  growth  which  mostly  involves  their  glandular 
elements,  although  there  is  some  general  increase  in  size  and  amount 
of  the  supporting  structures.  This  activity  is  synchronous  with  the 
appearance  of  spermatozoa ;  and  the  combined  secretions  of  the  testes, 
prostate,  seminal  vesicles,  and  Cowper's  glands  constitute  the  semen. 
This  is  a  glairy,  semimucilaginous  fluid,  of  uneven  consistency,  giving 
off  a  characteristic  odor.  It  is  probable  that  these  combined  secretory 
products  of  the  accessory  genital  glands  act  to  preserve  the  life  and 
motility  of  the  spermatozoon,  though  the  role  played  by  any  individual 
gland  is  still  quite  uncertain.  We  do  know,  however,  that  the  seminal 
vesicles  act  as  reservoirs  for  the  spermatozoa,  besides  furnishing  a 
secretion  to  the  semen. 

From  the  many  and  diverse  observations  on  this  subject  it  seems 
probable  that  the  prostatic  and  vesicular  secretion  acts  on  the  sper- 
matozoa in  a  physical  as  well  as  in  a  specific  physiological  manner.  In 


550     ANATOMY  AND  PHYSIOLOGY  OF  THE  SEMINAL  VESICLES 

the  case  of  human  spermatozoa  it  has  been  shown  that  the  duration  of 
their  activity  outside  the  body  depends  in  a  large  measure  on  the  re- 
action of  their  surrounding  medium.  An  acid  medium  slows  their 
motility,  or  entirely  suspends  it,  while  a  weakly  alkaline  one  seems  most 
favorable.  Analogous  results  are  shown  clinically  in  some  cases  of 
chronic  prostatitis  and  vesiculitis,  in  which,  though  many  spermatozoa 
are  found,  they  are  all  without  motion.  And  in  such  cases  their 
motility  is  regained  on  subsidence  of  the  infection.  Such  findings  are 
best  explained  by  a  change  in  the  reaction  of  the  semen  caused  by  the 
bacterial  invasion. 

It  has  further  been  shown  that  spermatozoa  placed  in  a  physiological 
salt  solution  do  not  live  as  long  as  do  those  in  the  semen.  But  the  view 
expressed  by  Fiirbringer,5  that  the  prostatic  and  vesicular  secretion 
causes  the  spermatozoa,  normally  motionless,  to  assume  motility,  ap- 
pears at  present  untenable.  For,  in  man,  motile  spermatozoa  have 
been  found  frequently  in  the  fluid  of  spermatoceles;  and  in  exploratory 
revision  of  the  epididymis  in  cases  showing  sterility,  the  writer  has  re- 
peatedly demonstrated  motile  spermatozoa  in  the  globus  major.  But 
though  spermatozoa  obtained  from  the  epididymis  do  show  motion, 
it  is  probable  that  this  is  much  better  maintained  in  the  midst  of  the 
normal  secretions  of  the  accessory  glands. 

The  physical  properties  of  the  semen  in  respect  to  its  viscosity  seem 
also  to  play  a  part,  it  being  well-known  that  human  semen  becomes 
more  limpid  and  homogeneous  after  standing  than  when  it  is  first 
ejaculated,  even  though  the  normal  temperature  is  maintained.  It  is 
probable  that  the  more  fluid  portion  of  the  semen,  coming  from  the 
prostate,  has  a  dissolving  action  on  the  globular  masses  which  come 
from  the  seminal  vesicles.  This  would  tend  to  facilitate  motion  in 
those  spermatozoa  held  in  the  vesicles. 

Attempts  have  been  made  to  gain  light  on  the  physiology  of  these 
organs  through  experimental  extirpation  in  animals,  and  though  it  is 
very  unsafe  to  draw  parallel  deductions  in  such  a  highly  specialized 
biological  phenomenon  as  that  of  procreation,  these  experiments  seem 
to  be  followed  by  sterility,  though  potency  is  retained. 

The  intimate  physiological  relation  between  the  prostate  and  the 
gonads  is  wrell  shown  in  the  marked  glandular  shrinkage  following 
orchidectomy;  or  if  carried  out  before  puberty,  in  the  complete  failure 
of  the  prostate  to  take  on  its  adult  character. 

That  the  prostate  has  also  an  internal  secretion — at  least  in  dogs — 
would  seem  to  be  quite  well  established  by  the  work  of  Serrallach  and 
Pares.13  Following  a  complete  prostatectomy  these  investigators 
obtained  atrophy  and  diminution  in  volume  of  the  testes,  with  suspen- 
sion of  spermatogenesis.  In  these  animals  intravenous  injection  of  a 
glycerin  extract  of  the  prostate  caused  the  reappearance  of  spermato- 
zoa, as  did  also  a  subcutaneous  graft  of  prostatic  tissue. 

Muscular  Apparatus. — The  musculature  of  the  prostate  takes  part  ir 
two  physiological  functions — those  of  micturition  and  of  ejaculation 
In  the  latter  the  seminal  vesicles  also  play  a  part. 


PHYSIOLOGY  551 

In  micturition  the  internal  sphincter  of  the  bladder  is  brought  into 
play.  This  group  of  smooth  muscle  fibers  forms  the  involuntary  por- 
tion of  the  mechanism  controlling  bladder  closure.  Between  the  acts  of 
urination  this  muscle  is  in  constant  tonus.  It  is  still  not  entirely  clear 
at  what  moment  in  the  chain  of  events  leading  to  urination  it  receives 
its  stimulus  to  relax,  or  what  the  degree  of  bladder  distention  must  be  to 
call  forth  this  stimulus.  Indeed,  writers  on  the  physiology  of  micturi- 
tion are  not  at  present  in  entire  agreement  on  the  subject.  This  is  a 
matter,  however,  which  falls  outside  the  scope  of  the  present  article. 
It  is  important  to  note  only  that  the  sphincter  internus  is  definitely  a 
part  of  the  prostate,  and  that  it  is  dependent  on  an  efficient  connection 
with  its  nervous  centres  for  its  constant  tonus. 

The  arrangement  of  the  muscle  fibers  about  the  prostatic  follicles  in 
a  circular  fashion,  while  they  are  longitudinally  placed  about  the  ducts, 
permits  forcible  and  quick  extrusion  of  the  contents  of  the  gland  at  the 
period  of  ejaculation.  The  same  is  true  of  the  musculature  of  the 
seminal  vesicles.  In  certain  animals  stimulation  of  the  appropriate 
nerves  calls  forth  a  contraction  of  the  vesicle,  in  which  the  organ  be- 
comes shorter,  while  at  the  same  time  its  circumference  is  narrowed 
by  a  wave  of  constriction  beginning  at  the  upper  pole  and  travelling 
downward.  Thus  the  contents  of  both  prostate  and  vesicle  reach  the 
urethra  quickly,  where  by  the  direction  of  the  openings  of  the  prostatic 
and  ejaculatory  ducts  they  are  intimately  mixed. 

It  has  been  held  by  some  that  the  semen  is  prevented  from  entering 
the  bladder  by  a  swelling  of  the  verumontanum  which  takes  place  be- 
fore ejaculation  occurs.  The  weight  of  evidence  is  against  this  view, 
however.  Complete  closure  of  the  vesical  sphincter,  which  is  present 
during  erection,  is  undoubtedly  sufficient  to  meet  this  need.  That  such 
closure  is  of  considerable  intensity  is  well  demonstrated  by  the  unusu- 
ally marked  voluntary  efforts  which  must  be  made  to  secure  relaxation 
of  the  sphincter  and  subsequent  urination  in  the  presence  of  erection. 

Nerve  Supply. — Much  has  still  to  be  learned  concerning  the  function 
of  the  very  complex  nervous  mechanism  of  the  prostate  and  seminal 
vesicles.  From  the  investigations  of  von  Zeissel  it  would  seem  that 
the  hypogastrics  are  the  true  secretory  nerves  of  these  organs.  Motor 
nerves  also  exist;  some  in  the  hypogastrics,  some  in  the  nervi  erigentes 
coming  from  the  anterior  sacrals.  The  significance  of  the  ganglion 
cells  and  of  nerves  showing  special  end-organs  is  entirely  unknown, 
though  for  the  latter  it  may  be  surmised  that  they  have  to  do  with  the 
sensual  phase  of  the  act  of  coitus.  The  importance  of  the  nerve  supply 
in  the  region  of  the  verumontanum  is  undoubtedly  great,  though  here 
again  clear-cut  data  are  lacking.  Clinically,  many  abnormalities  have 
been  ascribed  to  inflammation  located  here,  some  justly,  others  without 
any  clear  evidence.  Diminished  sexual  sensation,  impotence,  pre- 
mature ejaculation,  among  others,  as  well  as  psychic  disturbances  such 
as  sexual  neurasthenia,  are  sometimes  said  to  be  due  to  lesions  of  this 
area.  However  this  may  be,  it  is  certain  that  the  nerves  situated  here 
play  a  large  part  in  the  sensory  side  of  the  act  of  coition. 


552     ANATOMY  AND  PHYSIOLOGY  OF  THE  SEMINAL  VESICLES 


BIBLIOGRAPHY. 

1.  Aversenq  and  Dieulafe:  Aponevroses  et  espaces  periprostatiques,  Ann.  d.  mal. 
d.  org.  genito-urin.,   1911,  xxix-1,   1. 

2.  Cosentino:  Sulla  distribuzione  del  tessuto  elastico  nella  prostata  dell'  uomo  e 
degli  animali.  Anat.  Anz.,  1905,  xxvi,  293. 

3.  Denonvilliers :  Propositions  d'anatomie  de  physiologic  et  de  pathologie.     Paris 
Thesis,  1837. 

4.  Fischel  and  Kreibich:  Ueber  Prostatasekretion,   Wien.  klin.  Wchnschr.,   1911, 
xxiii,  901. 

5.  Fiirbringer:  Ueber  Prostatafunktion  und  ihre  Beziehung  zur  Potentia  generandi 
der  Manner,  Berl.  klin.  Wchnschr.,  1886,  xxiii,  476. 

6.  Luna:  Ueber  Anordnung  und  Struktur  der  sympatischen  Ganglien  in  der  men- 
schlichen  Prostata,  Folia  neurol.,  1908,  ii,  220. 

7.  Lowsley:  Gross  Anatomy  of  the  Human  Prostate  Gland  and  Contiguous  Struc- 
tures, Surg.,  Gynec.  and  Obst.,  1915,  xx,  183.    The  Development  of  the  Human  Prostate 
Gland  with  Reference  to  the  Development  of  Other  Structures  at  the  Neck  of  the  Urinary 
Bladder,  Am.  Jour.  Anat.,  1912,  xiii,  299. 

8.  Miiller  and  Dahl:    Die  Innervierung  der  mannlichen  Geschlechtsorgane,  Deutsch. 
Arch.  f.  klin.  Med.,  1912,  cvii,  113. 

9.  Pallin:  Beitrage  zur  Anatomie  und  Embryologie  der  Prostata  und  der  Samen- 
blasen,  Arch.  f.  Anat.  u.  Physiol.,  1901,  i,  135. 

10.  Picker:  Studien   iiber   das   Gangsystem   der  menschlichen   Samenblase,   Berlin, 
1911. 

11.  Pousson  and  Desnos:    Encyclopedic  francaise  d'urologie,  Paris,  1914,  vol.  i,  O. 
Doin. 

12.  Porosz:  Daten  zur  Anatomie  der  Prostata,  Arch.  f.  Anat.  u.  Physiol.,  1913,  Sup. 
vol.,  172. 

13.  Serrallach  and  Pares:  La  secretion  interne  de  la  prostate,  Ann.  d.  mal.  d.  org. 
genito-urin.,  1911,  xxix-1,  625. 

14.  Stohr :  Bemerkungen  liber  die  Verbindungen  der  Lymphgefasssystem  der  Prostata, 
Anat.  Anz.,  1899. 

15.  Timofeew:    Ueber  ein  besondere  Art    von  eingekapselten  Nervenendigungen  in 
den  mannlichen  Geschlechtsorganen  bei  Saugethieren,  Anat.  Anz.,  1896,  xi,  44. 

16.  Voelcker:  Chirurgie  der  Samenblasen,  Neue  Deutsch.  Chir.,  1912,  ii. 

17.  Walker:  Beitrage  zur  Anatomie  und  Physiologie  der  Prostata  neben  Bemerkungen 
uber  den  Vorgang  der  Ejakulation,  Arch.  f.  Anat.  u.  Physiol.,  1899,  313. 

18.  Wilson  and  Magrath:  Surgical  Pathology  of  the  Prostate,  Surg.,    Gynec.  and 
Obst.,  1911,  xiii,  647. 


CHAPTER    XIX. 
PROSTATIC  OBSTRUCTIONS. 

URINARY  STASIS  DUE  TO  PRIMARY  HYPERPLASIA  OF  THE  ELEMENTAL 
TISSUES  OF  THE  PROSTATE. 

BY  PAUL  MONROE  PILCHER,  A.M.,  M.D. 

PROSTATIC  obstructions  have  long  been  recognized  as  a  cause  of 
urinary  stasis.  The  history  of  its  recognition,  and  of  the  attempts  to 
remedy  the  local  consequences  of  its  development,  goes  hand  in  hand 
with  the  gradual  growth  of  our  knowledge  of  anatomy,  pathology,  and 
surgical  technic.  The  desperate  need  of  relief  in  many  cases  led  to  the 
employment  at  first  of  crude  and  cruel  means  of  overcoming  the  obstruc- 
tion— at  first,  forced  catheterization  and  bold  tunnelling  of  the  prostate 
through  the  urethra — later  forcible  compression  within  the  prostatic 
urethra.  Occasionally  we  read  of  suprapubic  puncture  and  supra- 
pubic  and  perineal  cystotomy  in  emergency  cases. 

The  history  of  this  subject  has  been  frequently  written,  but  to 
my  mind  contains  very  little  of  real  interest,  until  the  latter  half  of 
the  19th  Century.  Mercier's  "  prostatectome,"  devised  by  him  in 
1837,  was  the  first  instrument  employed,  which  gave  promise  of 
permanent  relief.  Bottini,  in  1873,  improved  this  instrument  by  the 
use  of  a  galvanocautery  incisor.  This  method  of  Bottini  was  exten- 
sively tried  by  various  surgeons,  and  for  several  years  had  considerable 
vogue,  but  latterly  it  has  been  entirely  displaced  by  the  more  modern 
surgical  procedures. 

Many  surgeons  in  the  course  of  their  work,  involving  lesions  of  the 
prostate,  removed  obstructing  portions  of  the  gland,  but  the  mortality 
was  so  alarming  that  most  men  preferred  to  employ  the  less  radical 
measures,  such  as  establishing  a  permanent  suprapubic  fistula,  perineal 
drainage,  partial  cautery  destruction  of  the  gland,  removal  of  the  tes- 
ticles, vasectomy,  etc.,  all  of  which  met  with  a  certain  measure  of 
success.  Belfield,  in  1887,  advocated  suprapubic  prostatectomy,  and  in 
1888  McGill,  of  Leeds,  published  his  monograph  recommending  supra- 
pubic prostatectomy. 

Fuller  (1895)  was  the  first  in  this  country  to  work  out  a  satisfactory 
technic  for  suprapubic  prostatectomy.  This  method  of  prostatectomy 
was  not,  however,  popularly  received  until  the  technic  of  Freyer  was 
published  in  1901.  His  teachings  of  the  after-treatment,  which,  how- 
ever, differed  from  that  of  Fuller  in  no  essential  respect,  have  been  of 
the  greatest  importance,  and  he  was  the  first  to  show  the  results  of 
this  operation  in  a  large  series  of  cases. 

(553) 


554  PROSTATIC  OBSTRUCTIONS 

Perinea!  prostatectomy  likewise  had  been  accomplished  many  times 
by  various  men,  notably  Albarran  and  Proust  in  France,  but  it  remained 
for  H.  H.  Young,  of  Baltimore,  in  1903  to  work  out  a  satisfactory  technic 
for  its  performance.  He  published  a  large  series  of  cases  operated  by 
this  method  and  showed  a  remarkably  low  mortality  rate. 

There  still  remained  much  to  be  desired.  The  methods,  both  supra- 
pubic  and  perinea!,  while  reasonably  safe  in  the  hands  of  a  few  experts, 
when  attempted  by  the  general  surgeon,  as  was  often  necessary, 
resulted  in  a  relatively  high  mortality.  The  combined  work  of  many 
urologists  resulted  in  the  general  adoption  of  a  period  of  preliminary 
treatment  in  all  cases  of  urinary  stasis.  Periodic  catheterization, 
continuous  drainage  of  the  bladder,  renal  decompression,  became 
recognized  preliminaries  to  prostatectomy.  Finally  the  two-stage 
transvesical  prostatectomy,  which  is  an  operation  that  is  reasonably 
safe  in  the  hands  of  the  general  surgeon,  was  established. 

ANATOMY  OF  THE  PROSTATE. 

The  anatomy  of  the  prostate  has  been  given  in  detail  in  a  previous 
chapter,  so  the  details  need  not  be  repeated  here.  Surgically  we  have 
come  to  recognize  that  the  prostate  is  divisible  into  five  lobes :  the  two 
lateral  lobes,  the  middle  lobe,  the  posterior  lobe,  and  the  anterior  lobe.6 

The  fact  is  that  the  prostate  is  described  as  divided  into  lobes  only 
because  it  consists  primarily  of  five  buds  jutting  out  from  the  posterior 
urethra.  Each  bud  represents  a  collection  of  tubules  which  later 
develop  into  secreting  glandular  masses  which  finally  fuse  and  form  into 
a  single  body  called  the  prostate  gland.  If  one  were  to  attempt 
division  of  the  normal  prostate  into  lobes  basing  his  judgment  on  the 
gross  appearance  of  the  gland  in  its  normal  state  it  would  be  very  diffi- 
cult. Therefore,  to  my  mind,  it  is  of  very  little  moment  whether  we 
recognize  certain  definite  subdivisions  of  the  gland,  or  not,  if  we  but 
keep  in  mind  the  fact  that  the  gland  develops  from  five  distinct  buds, 
and  we  may  designate  their  end-development  as  we  will. 

PATHOLOGY  OF  THE  PROSTATE. 

It  is  unfortunate  that  a  more  fitting  term  has  not  been  universally 
accepted  to  designate  the  general  condition  of  urinary  stasis  due  to 
non-malignant,  non-inflammatory  changes  in  the  prostate  gland.  The 
designation  hypertrophy  of  the  prostate  is  often  incorrect,  for  we 
frequently  see  cases  in  which  the  gland  is  not  enlarged,  and  yet  the 
interstitial  changes  are  sufficient  to  cause  obstruction  and  urinary 
stasis.  I  refer  to  the  cases  of  muscular  and  fibrous  hyper plasia  and  not 
infrequently  cases  of  irregular  glandular  hyperplasia  with  enlargements. 
This  chapter  dealing  with  urinary  stasis  also  must  include  the  cases 
of  hyperplasia  of  the  submucous  and  subcermcal  glands  which  cause 
obstruction.  To  speak  of  chronic  "prostatism"  is  also  incorrect,  for 
such  a  term  would  lead  us  to  believe  that  we  were  dealing  with  a  chronic 


PATHOLOGY  OF  THE  PROSTATE  555 

disease  of  the  prostate,  in  which  the  pathological  conditions  in  the 
prostate  were  giving  rise  to  the  symptoms  from  which  the  patient  is 
suffering,  while  in  fact  the  pathological  lesion  gives  rise  to  no  symptoms, 
as  a  rule,  but  acts  mechanically,  causing  urinary  stasis  which  in  its 
turn  causes  the  local  symptoms  and  the  more  far-reaching  systemic 
disorders.  Furthermore,  the  long-accepted  caption  "  prostatism  sans 
prostate"  is  a  catchy  phrase  absolutely  devoid  of  scientific  meaning 
and  should  be  discarded. 

"  Adenomatous  hypertrophy"  of  the  prostate  is  likewise  a  misnomer. 
The  term  hypertrophy  is  erroneously  substituted  for  hyperplasia,  or 
cytoplasia;  adenoma  of  the  prostate,  meaning  thereby  a  neoplasm,  is 
certainly  of  rare  occurrence.  Adenoma  of  the  prostate,  meaning  a 
benign  glandular  hyperplasia,  is  distinctly  different  from  "adenoma- 
tous"  conditions,  and  the  two  terms  should  not  be  interchanged.  An 
adenoma  is  a  true  neoplasm  developing  from  proliferating  glandular 
tissue.  Glandular  hyperplasia  of  the  prostate  is,  unlike  adenoma, 
not  a  reproduction  but  a  reduplication  of  cells  and  acini,  and,  unlike 
adenoma,  conforms  as  much  in  its  microscopic  as  in  its  gross 
morphology  to  the  original  glandular  structure.  Glandular  hyper- 
plasia of  the  prostate,  which  is  a  multilobular  gland,  may  manifest 
itself  as  discreet,  nodular  tumefactions  which  are  somewhat  enucleat- 
able.  This  is  only  an  expression  of  the  structure  of  the  gland  wherein 
the  various  anatomical  units  have  undergone  hyperplasia  and  is  not  to 
be  confounded  with  adenomata  which  are  rarely  multiple. 

Excluding  syphilis,  tuberculosis  and  cancerous  lesions  of  the  pros- 
tate, the  non-inflammatory  enlargements  of  the  prostate  are  either 
cytological  or  mechanical,  viz. : 

(a)  of  the  parenchyma. 


1.  Cytological  hyperplasia 


(6)  of  the  strom a. 


(c)  of  both. 

2.  Mechanical — due  to  retention  of  gland  contents  with  cystic 
dilatation. 

In  addition  to  this  we  have  deformities  in  and  about  the  prostate 
due  to  inflammation  and  irregularities  of  development  of  accessory 
glands  which  cause  symptoms  similar  to  hypertrophy  of  the  prostate. 

Hyperplasia  of  the  accessory  glandular  structure,  i.  e.,  the  submucous 
and  subtrigonal  glands.  These  are  so  closely  associated  with  the  pros- 
tate that  they  are  often  difficult  of  differentiation.  Situated  as  they 
are  at  the  outlet  of  the  bladder,  hyperplasia  of  these  gland  groups 
causes  urinary  obstruction  just  as  do  the  prostatic  enlargements. 

Gross  Pathology. — Our  understanding  of  the  gross  pathology  of 
prostatic  obstruction  has  changed  but  little  in  the  past  ten  years. 
The  most  interesting  contributions  have  been  from  Tandler  and 
Zuckerkandl,12  Lowsley,7  Wilson  and  McGrath,17  and  Henry  Wade.14 
The  chief  difference  of  opinion  is  in  the  interpretation  of  the  gross 
specimens  removed.  Practically,  these  differences  are  of  no  importance. 
All  agree  that  the  glandular  hyperplasia  does  not  affect  the  entire  gland 
at  one  time;  but  usually  starts  in  the  median  and  lateral  lobes,  and 


556 


PRO  STATIC  OBSTRUCTIONS 


gradually  increasing,  presses  aside  the  overlying  gland  structures, 
causing  their  gradual  atrophy  and  surrounding  the  hyperplastic  mass 
by  a  false  capsule  composed  of  the  atrophied  shell  of  prostatic  tissue 
together  with  fibrous  and  muscular  tissue.  Also,  a  recognition  of  the 
fact  that  a  prostate  which  has  not  a  false  capsule  of  this  type  is  difficult 
of  enucleation.  This  is  true  of  the  cases  of  fibrous  and  muscular 
hyperplasia  and  the  obstructive  lesions  due  to  inflammation.  Also, 
there  seems  to  be  increasing  evidence  that  the  suburethral  and  sub- 
trigonal  groups  of  glands  which  are  closely  associated  with  the  prostatic 
gland,  become  hyperplastic  and  cause  obstruction. 


FIG.  240. — Note  relation  of  capsule  A,  A,  to  glandular  structure;  also  distortion  of  the 
urethra  and  distribution  of  glandular  and  fibromuscular  hypertrophy. 

Examining  the  gross  specimens  we  find  the  large,  soft  prostate,  the 
small,  hard  prostate  and  a  mixed  type. 

The  large,  soft  type  is  composed  of  masses  of  glandular  tissue  pre- 
senting all  degrees  of  change  from  the  normal  alveoli  to  the  formation 
of  cysts  and  large  adenomatous-like  masses.  There  is  a  relative  and 
absolute  increase  in  the  amount  of  glandular  tissue  and  in  varying 
degrees  a  relative  and  absolute  increase  in  the  amount  of  fibrous  and 
muscular  tissue. 

The  ducts  are  in  many  places  dilated  and  filled  with  retained  secre- 
tion, often  degenerated  epithelium,  leukocytes,  amylaceous  bodies  and 
calculi.  These  contents  may  even  obstruct  the  ducts.  In  the  tissue 


PATHOLOGY  OF  THE  PROSTATE 


557 


surrounding  the  ducts  are  often  seen  round  cells  and  polymorpnonuclear 
leukocytes.     In  some  places  the  ducts  are  seemingly  constricted. 

The  glands  and  acini  are  greatly  but  unevenly  dilated  and  enlarged. 
A  whole  lobule  may  be  enlarged  without  any  dilatation  of  the  acini, 
presenting  the  appearance  of  an  adenoma,  but  differing  from  it  in  that 


FIG.  241. — Showing  relation  of  the  mucosa  of  the  prostatic  urethra  to  the  substance 
of  the  prostate.  Camera  lucida  drawing  from  same  section  as  Fig.  240.  Note  the 
intimate  relation  between  the  epithelial  layer,  A,  and  the  underlying  fibromuscular 
layer,  B,  which  is  not  in  any  way  differentiated  from  the  musculo-glandulo-fibrous  layer, 
C,  which  makes  up  the  bulk  of  the  hypertrophied  prostate.  In  the  musculofibrous  layer, 
B,  the  muscular  elements  predominate. 

it  has  a  definite,  active  secretion  which  is  emptied  into  the  urethra  by 
the  ducts.  A  small  portion  of  a  lobule  or  a  single  acinus  may  be 
affected. 

My  own  observations  as  to  the  relative  change  in  the  amount  of 
muscular  tissue  in  the  hypertrophied  prostate  do  not  agree  entirely 


558 


PROSTATIC  OBSTRUCTIONS 


with  that  of  other  workers.  The  two  coats  surrounding  the  dilated 
acini  do  not  show  as  distinct  a  differentiation  as  in  the  young  prostate. 
From  the  nature  of  the  glandular  change  it  is  natural  to  suppose  that 
the  surrounding  tissue  will  be  distorted,  but  not  necessarily  changed 
relatively.  It  is  only  when  the  wall  between  two  adjacent  acini 
becomes  thinned  down  to  one  or  two  layers  of  cells  that  the  muscular 
fibers  disappear  (Fig.  242  and  243),  and  only  the  connective-tissue 
framework  remains.  In  fact,  in  many  cases  the  muscular  tissue  shows 
a  moderate  but  true  hyperplasia. 


FIG.  242. — Exact  drawing  from  a  portion  of  an  hypertrophied  and  dilated  lobule. 
Showing  the  thinning  out  of  the  musctilofibrous  stroma.  The  lighter  areas  of  the  stroma 
represent  muscular  tissue  and  the  heavier  lines  connective  tissue.  In  some  places  the 
walls  separating  the  acini  have  disappeared. 

The  amount  of  connective  tissue  varies  in  different  specimens.  Most 
observers  claim  that  it  is  everywhere  increased,  but  not  relatively  as 
much  as  the  glandular  tissue.  It  is  true  that  in  many  cases  the  con- 
nective tissue  is  increased  relatively,  but  sometimes  the  proportion  of 
muscular  hyperplasia  is  almost  as  great  as  the  connective-tissue  increase. 
Throughout  this  tissue  at  different  points,  varying  degrees  of  round-cell 
infiltration  are  to  be  seen.  In  some  cases  arteriosclerosis  of  an  advanced 
stage  is  present.  In  many  of  our  cases  there  were  seen  areas  of  extra va- 
sated  blood.  Again  are  seen  areas  of  normal  tissue. 

In  the  atrophic  prostates,  two  forms  have  been  observed:  The  first 
in  which  the  glandular  elements  are  decreased  and  smaller  than  normal. 
In  these  prostates  the  amount  of  muscular  tissue  present  seems  to 


PATHOLOGY  OF  THE  PROSTATE 


559 


exceed  the  amount  of  new  connective  tissue,  which  in  some  cases  is 
relatively  diminished.  In  one  case  the  predominance  of  muscular 
tissue  was  very  marked.  The  second  form  presents  a  combination  of 
compressed  glands  which  predominate,  and  a  few  dilated  hypertrophied 
lobules,  which,  however,  never  reach  any  considerable  size. 

Concerning  the  Portions  of  the  Gland  Involved. — Lowsley  agrees  with 
the  more  advanced  pathologists  and  recognizes  five  lobes  in  the  pros- 
tatic  mass.  The  middle  lobe  is  quite  independent  of  the  others  and  its 
tubules  are  distinctly  separated  from  the  others.  They  are  situated 
within  the  gland  structure  and  are  in  relation  with  the  floor  of  the 


FIG.  243. — Exact  drawing  from  periphery  of  same  lobule  as  shown  in  Fig.  242.  Show- 
ing a  sclerosed  vessel  whose  lumen  is  represented  by  a  single  line  of  endothelial  cells,  C. 
Note  how  the  vessel  wall  is  separated  from  the  fibromuscular  structures  of  the  lobule, 
just  as  the  fibromuscular  capsule  of  the  gland  is  from  the  glandular  body  itself.  Small 
areas  of  extravasated  blood  and  round-cell  infiltrations  are  seen. 

urethra.  The  posterior  lobe  is  situated  farthest  from  the  bladder  and 
is  almost  an  independent  structure.  It  is,  further,  of  interest  to  note 
that  the  tubules  of  the  middle  lobe  lie  side  by  side  with  those  of  the 
lateral  lobes,  but  at  no  point  do  they  intermingle.  The  lateral  lobes 
are  made  up  of  a  series  of  tubules  on  each  side  of  the  urethra  and  the 
acini  of  these  lobes  form  the  main  mass  of  the  gland.  It  is  distinctly 
indicated  that  the  lateral  lobes  are  in  direct  relation  with  the  urethra. 
The  posterior  lobe  seems  to  be  almost  an  independent  structure  and  is 
seldom  involved  in  hypertrophy  of  the  gland.  It,  however,  seems  to  be 
a  starting-point  for  malignant  degeneration  in  many  cases. 


560 


PROSTATIC  OBSTRUCTIONS 


The  theories  of  Tandler  and  Zuckerkandl  demand  careful  study. 
They  hold  that  in  all  cases  of  prostatic  hypertrophy  the  glandular 


FIG.  244. — Sagittal  view  of  a  wax  model  of  the  prostate  of  a  newborn  infant.  X  14. 
(From  Lowsley.)  Lai.,  anterior  branches  of  lateral  lobes;  P.L.,  posterior  lobe;  E.J., 
ejaculatory  duct;  S.V.,  seminal  vesicle;  A. L.,  anterior  lobe  tubule;  U.,  urethra;  U.P., 
utriculus  prostaticus;  A.G.,  subcervical  glands  of  Albarran;  M.L.,  middle  lobe  tubules; 
L.Ur.,  left  ureter;  BL,  bladder;  P.GL,  prostate  gland. 


Venfral  or  Aftlenor  Lobe. 


Middle  Lobe • 


Lateral  Lob 


Ejaculafory  Due 


Ufriculus 
Prosfaricus . 


FIG.  245. — Cross-section  through  middle  lobe  of  prostate.     (Lowsley.) 

hyperplasia  starts  in  the  middle  lobe;  in  other  words,  the  gland  group 
which  buds  from  the  floor  of  the  urethra  is  the  starting-point  of  the 


PATHOLOGY  OF  THE  PROSTATE 


561 


obstruction  and  it  extends  upward  into  the  bladder  and  laterally  around 
the  urethra.  The  extended  observations  of  other  pathologists  do  not, 
however,  confirm  this.  All  are  agreed  that  the  posterior  lobe  does 
not  share  in  the  hyperplasia. 

al  lobe  tubules. 


Urethra. 


Lflferdl 
Lobe. 


cle  R-oslalici/s. 

EjaculaJorvj  Duci. 
tr/iV>^v'<^-:i*j^       "J  7 

t2*>~-^><^|J27 
FIG.  246. — Cross-section  through  prostate  and  the  ejaculation  ducts  below.    (Lowsley.) 

If  enlargement  of  the  median  lobe  takes  place,  it  must  proceed 
along  the  avenue  of  least  resistance,  which  is  through  the  vesical  outlet, 
gradually  dilating  it  and  forcing  the  sphincter  ring  wide  open.  That 


Trigonun 
Vesicca 


Posterior 
Lobe. 


FIG.   247. — Longitudinal   section    through   neck   of    bladder,    prostate   and    posterior 

urethra.     (Lowsley.) 

this  frequently  occurs  is  well  shown  by  many  specimens.  However,  it 
is  hard  to  accept  the  theory  that  in  some,  or  in  many  cases,  the 
enlargement  of  the  median  lobe  takes  place  in  the  direction  of  the  lateral 
lobes,  displacing  them  and  causing  atrophy  of  these  lobes,  compressing 
M  u  i — 36 


562 


PROSTATIC  OBSTRUCTIONS 


them  out  into  a  shell-like  capsule;  to  produce  a  lateral  extension  of  an 
enlarging  median  lobe,  the  expansion  must  take  place,  not  along  the 
avenue  of  least  resistance/but  against  a  firm,  well-developed  structure. 
Judging  from  the  anatomical  relations  as  found  on  the  operating  table, 
Tandler's  conclusions  as  to  the  part  of  the  prostate  involved  in  the 
obstruction  are  incorrect. 


FIG.  248. — Sagittal  section  through  the  pelvis,  showing  the  prostate  hypertrophied. 
(Tandler  and  Zuckerkandl.) 


Fig.  248  is  an  illustration  taken  from  the  work  of  Tandler  and 
Zuckerkandl,  showing  a  sagittal  section  of  the  pelvis  in  a  case  of  pros- 
tatic  hypertrophy.  We  agree  that  this  represents  a  typical  case  of 
median  lobe  enlargement.  A  number  of  other  illustrations  which  are 
shown  in  the  work  of  Tandler  and  Zuckerkandl  are  unquestionably 
examples  of  median  lobe  enlargement,  for  in  each  the  hyperplastic  mass 
is  more  or  less  symmetrical  in  the  median  line  and  is  forced  through  the 


PATHOLOGY  OF- THE  PROSTATE 


563 


sphincter  dilating  it.  The  same  phenomenon  has  been  plainly  shown 
in  many  of  our  own  specimens.  For  example,  Figs.  249,  250  and  251. 
At  the  same  time  the  enlargement  of  the  lateral  lobes  without  the, 
median  lobe  enlargement  may  take  place,  and  in  such^cases  the  sphincter 
is  greatly  dilated  and  surrounds  the  hyperplastic  mass.  Such  a  case  is 
seen  in  Fig.  252.  In  this  case  the  lateral  lobes  have  become  enormously 
hypertrophied  and  have  carried  the  median  lobe,  which  is  also  enlarged, 
through  the  sphincter  well  into  the  bladder.  It  cannot  be  conceived 
that,  after  the  enucleation  which  was  accomplished  in  this  case,  much 
prostatic  tissue  was  left  behind,  unless  it  was  the  posterior  lobe  which  is 
so  nearly  independent.  Fig.  253,  however,  shows  a  different  condition. 


t 


FIG.  249. — Prostatic  mass  removed  by  transvesical  operation,  rubber  tube  showing 
direction  of  urethra.  Beneath  the  rubber  tube  is  a  greatly  hypertrophied  middle  lobe. 
The  lateral  lobes  are  seen  forming  the  sides  and  roof  of  the  urethra,  but  are  not  in  any 
way  obstructive. 


This  was  a  case  of  complete  urinary  obstruction  which  had  lasted  for 
three  years.  B',  B',  are  the  enlarged  lateral  lobes.  B  is  a  greatly 
hypertrophied  median  lobe.  A  is  a  crescent-shaped  calculus,  and  the 
remaining  pieces  of  tissue  are  compressed  and  atrophied  bits  of  prostatic 
tissue  which  still  remained  imbedded  in  -the  capsule  of  the  prostate 
after  the  hyperplastic  masses  had  been  enucleated.  Fig.  254  is  an 
example  of  symmetrical  enlargement  of  the  median  and  both  lateral 
lobes.  Fig.  255  is  an  example  of  bilateral  hypertrophy  without  any 
median  lobe  enlargement.  The  specimen  is  very  distinct  and  convinc- 
ing on  this  point.  Fig.  256  is  another  example  of  irregular  hypertrophy 
of  the  lateral  lobe  with  very  little  median  lobe  enlargement.  Fig.  257 


564 


PROSTATIC  OBSTRUCTIONS 


'ait?  Pile  her* 


FIG.  250. — Enormous  median  lobe  enlargement  of  the  prostate  with  adenomatous 
changes  in  the  lateral  lobes.  These  lobes  are  smaller  than  normal  and  show  no  atrophy 
due  to  pressure.  The  specimen  presents  a  view  of  the  anterior  face.  The  part  above 
the  rubber  tube  was  entirely  intravesical.  The  anterior  face  is  covered  by  mucous 
membrane. 


Bight  Lobe 


Median    Lobe 


FIG.  251. — Drawing  showing  the  three  lobes  of  the  prostate  separated.     Same  specimen 

as  Fig.  250. 


PATHOLOGY  OF  THE  PROSTATE  565 

shows  a  specimen  removed  in  one  piece  in  which  the  median  lobe  is 
enlarged  and  has  pushed  forward  into  the  bladder  and  distorts  the 
urethra,  lifting  it  up  and  making  it  almost  impossible  to  empty  the 
bladder.  The  position  of  the  sphincter  is  indicated  by  the  arrows. 
Fig.  258  shows  still  another  type  of  development.  The  lateral  lobes  in 
this  case  had  been  previously  removed  by  perineal  operation.  The 
symptoms  persisted  and  three  years  later  this  median  lobe  enlargement, 
with  a  very  freely  movable  ball-valve  attachment,  wras  taken  out  by  a 
transvesical  operation.  No  remnants  of  the  lateral  lobes  could  be 
found.  It  is  interesting  to  note  the  position  of  the  internal  sphincter  as 
indicated  by  the  arrows.  In  this  case  we  had  the  obstruction  of  the 
enlarged  mass  and  in  addition  a  ball-valve  action. 


FIG.  252. — Photograph  of  hypertrophied  prostate  removed  by  suprapubic  route, 
showing  bilateral  and  median  enlargement.  At  vesical  pole,  A,  the  capsule  and  mucous 
membrane  of  the  bladder  are  shown  stripped  back  from  the  glandular  portion  of  the 
gland.  At  B  is  seen  the  circular  capsule  which  passes  entirely  around  the  gland. 

Fig.  260  is  the  photograph  of  a  specimen,  actual  size,  removed  in  one 
piece.  It  is  a  perfect  example  of  enlargements  of  both  lateral  lobes  of 
the  prostate.  Fig.  259  shows  a  section  through  the  centre  of  this  mass 
and  shows  quite  distinctly  the  three  lobes,  the  two  lateral  lobes  and  the 
median  lobe,  and  their  position  in  relation  to  the  urethra.  The  median 
lobe  extends  upward  like  a  wedge  between  the  two  lateral  lobes  and 
is  only  moderately  enlarged.  In  this  connection  reference  may  be 
made  to  the  series  of  photographs  of  specimens  which  were  published 
in  1888  by  Francis  S.  Watson,  of  Boston,  in  his  treatise  on  the  Opera- 
tive Treatment  of  Hypertrophy  of  the  Prostate.  Fig.  261  shows 
very  important  feature;  the  lateral  lobes  are  moderately  enlarged,  the 
median  lobe  is  distinctly  enlarged  and  is  projecting  into  the  bladder, 


566 


PROSTATIC  OBSTRUCTIONS 


FIG.  253. — Photograph  of  prostatic  masses  removed  by  transvesical  route.  A  is  a 
crescent-shaped  calculus;  B,  a  large  median  lobe;  B',B'  the  two  lateral  lobes.  The  other 
pieces  of  tissue  shown  in  the  specimen  are  atrophied  prostate  tissue  adherent  to  the 
capsule. 


PATHOLOGY  OF  THE  PROSTATE 


567 


forming  the  cause  of  the  obstruction.  Distal  to  the  median  lobe 
enlargement  is  seen  a  raised-up  portion,  which  is  the  colliculus  or 
verumontanum,  at  which  point  the  vasa  deferentia  empties  into  the 


FIG.  254. — Specimen  removed  by  transvesical  operation,  showing  symmetrical 
enlargement  of  both  median  and  lateral  lobes. 

urethra.     If  the  finger  is  introduced  into  the  urethra  by  the  transvesical 
route  in  enucleating  the  prostate,  one  can  easily  see  from  the  specimen 


FIG.  255. — Specimen  removed  by  transvesical  operation,  showing  hypertrophy  of  lateral 
lobes  without  involvement  of  median  lobes. 

how  the  colliculus  may  be  preserved.  Fig.  262  is  an  undeniable  example, 
of  enlargement  of  both  the  lateral  and  median  lobes  of  the  prostate. 
This  specimen  which  is  a  dissection  not  only  of  the  prostate  but  of  the 


568 


PROSTATIC  OBSTRUCTIONS 


bladder  as  well,  shows  exactly  the  relation  which  no  drawing  could  so 
well  express.  The  tortuous  course  of  the  urethra,  the  presence  of  the 
colliculus  and  its  relative  position  are  clearly  shown.  No  one  could 


FIG.  256.- 


-Specimen  removed  by  transvesical  operation,  showing  irregular  hypertrophy 
of  the  lateral  lobes  with  very  little  median-lobe  enlargement. 


argue  that  in  these  specimens  such  an  hypertrophy  originates  from  the 
median  lobe  alone.  The  floor  of  the  urethra  is  very  clearly  shown  and 
is  seen  to  be  free  from  all  hypertrophied  tissue.  This  portion  of  the 
urethra  must  invariably  be  involved,  at  least  that  portion  between  the 
colliculus  and  the  sphincter,  in  all  median-lobe  enlargements.  Fig.  263 


FIG.  257. — Specimen  removed  by  transvesical  operation,  showing  marked  median-lobe 
enlargement  with  practically  no  lateral-lobe  enlargement. 

is  a  perfect  example  of  median-lobe  enlargement  alone.  In  this  case 
the  lateral  lobes  are  distinct,  but  not  hypertrophied.  The  specimen 
shown  in  Fig.  264  shows  well  the  part  taken  by  the  lateral  lobes  in  some 


PATHOLOGY  OF  THE  PROSTATE 


569 


cases  of  obstructive  prostatic  overgrowth.     The  specimen  was  removed 
by  the  transvesical  route,  and  the  entire  deformed  portion  of  the  pros- 


FIG.  258. — Median-lobe  enlargement  with  ball-valve  attachment. 

tate  was  removed  in  one  piece.     Fig.  265  shows  the  under  surface  of 
this  prostatic  mass.    A  rubber  tube  passing  through  the  specimen  indi- 


FIG.  259. — Cross-section  of  specimen  shown  in  Fig.  260  showing  relation  of  median  lobe 
and  two  lateral  lobes  to  the  urethra. 

cates  the  position  of  the  urethra.     At  the  top  of  the  specimen  is  seen 
a  small  collar  which  is  the  mucous  membrane  stripped  up  from  the 


570  PROSTATIC  OBSTRUCTIONS 

internal  sphincter.  This  sphincter  could  be  appreciated  by  a  finger  in 
the  bladder.  Fig.  266  is  another  photograph  of  this  same  specimen 
viewed  from  the  anterior  surface,  showing,  roughly,  the  course  of  the 
urethra,  as  exaggerated  by  the  furrows  produced  by  the  presence  of  the 
rubber  tube  in  the  hardened  specimen.  The  two  lateral  lobes  which 
appear  like  the  wings  of  a  butterfly  are  joined  across  the  median  line 
by  a  practically  normal  median  lobe  which  is  not  enlarged.  The  collar 
of  mucous  membrane  also  appears  at  the  top  of  this  specimen  and  shows 


FIG.  260. — Enlargement  of  the  prostate  in  which  the  two  lateral  lobes  are  involved. 
The  vesical  surface  of  the  prostate  appears  at  the  top  of  the  picture.  This  specimen 
was  removed  within  its  capsule  and  is  a  perfect  example  of  coincident  hypertrophy 
of  both  lateral  lobes  without  any  marked  median-lobe  enlargement.  The  section'through 
this  mass  is  seen  in  the  preceding  figure  which  shows  the  narrow  cleft  occupied  by  the 
urethra.  The  two  lateral  masses  and  the  small  adenomatous  median  lobe  are  seen. 


the  lack  of  any  bulging  in  the  bladder.  As  far  as  could  be  appreciated 
by  the  finger,  the  entire  prostate  was  removed  in  this  case  with  the 
possible  exception  of  the  posterior  lobe  of  the  gland  which  was  distal 
to  the  ducts,  but  the  remains  of  which  could  not  be  appreciated  by 
the  finger.  Fig.  267  is  a  photograph  of  a  specimen  which  shows  the 
prostatic  mass  as  removed  in  one  piece.  The  small  drainage  tube 
occupies  the  position  of  the  distorted  urethra  and  shows  the  presence 
of  the  greatly  enlarged  median  lobe  which  extends  into  the  bladder  arid 


PATHOLOGY  OF  THE  PROSTATE 


571 


lifts  up  the  urethra.  The  bladder  in  this  case  is  to  the  right  of  the 
specimen.  As  one  views  the  gross  specimen,  it  would  look  as  if  the 
entire  mass  was  one  piece.  When,  however,  the  anterior  commissure 
is  divided,  the  specimen  falls  apart  and  forms  three  distinct  portions; 
the  twro  lateral  masses,  which  are  the  lateral  lobes,  are  greatly  enlarged 
and  compress  the  urethra,  the  course  of  which  is  indicated  by  the  furrow 


FIG.  261. — Hypertrophy  of  both  lateral  and  the  median  lobes.  The  Y-shape  taken 
Uy  the  prostatic  urethra  as  it  passes  on  either  side  the  median  enlargement  to  enter  the 
bladder  is  well  shown.  Reduced  \.  (.Watson.)  > 

(Fig.  2()S) .  To  the  loft,  in  the  upper  quadrant  of  the  picture,  is  seen  the 
median  lobe  which  extends  well  down  into  the  urethra,  well  past  the 
first  portion  of  the  lateral  lobes,  in  fact,  forming  a  wedge-shaped  lobe 
between  the  portions  of  the  lateral  lobes  which  extend  into  the  bladder. 
However,  the  specimen  clearly  shows  the  relations  of  the  two  lateral 
lobes  to  the  urethra.  Fig.  2(58  shows  another  view  of  this  same  gland 


572 


PROSTATIC  OBSTRUCTIONS 


which  indicates  more  clearly  the  exact  position  of  the  urethra  and  its 
relations  to  the  lateral  lobes  and  to  the  median  lobe.     In  this  specimen 


FIG.  262.— Bilateral  hypertrophy.     The  two  lateral  lobes  joined  by  a  bridge  or  median 
bar,  the  so-called  bar  at  the  neck  of  the  bladder.     Reduced  J.     (Watson.) 

one  lateral  lobe  has  been  removed  and  the  furrow,  as  indicated  in  the 
specimen,  shows  the  relation  of  the  urethra  to  both  the  lateral  and 
median  lobes.  _  The  lateral  lobe  forms  the  side  wall  for  over  two  inches, 
while  the  median  lobe  passing  beneath  the  urethra  extends  along  it  for 
an  inch  and  a  quarter. 


PATHOLOGY  OF  THE  PROSTATE 


573 


FIG.  263. — Hypertrophy  of  median  lobe  only.     (Watson.) 


FIG.  264. — Specimen  removed  by  transvesical  operation,  showing  the  entire  prostate 

removed  in  one  piece. 


574 


PROSTATIC  OBSTRUCTIONS 


Our  own  deductions  are  based  primarily  on  an  analytical  study  of  our 
own  cases,  taking  into  account  first,  the  conformation  of  the  prostatic 


FIG.  265. — Same  specimen  as.Fig.  264.  The  anterior  commissure  divided,  allowing  the 
hypertrophied  right  lobe  to  drop  down,  showing  the  relation  of  the  enlarged  middle  lobe 
and  the  left  lateral  lobe  to  the  urethra.  The  middle  lobe  is  seen  to  form  the  floor  of  the 
urethra  for  a  distance  of  about  1^  inches,  but  does  not  extend  as  far  up  on  the  urethra 
as  the  lateral  lobe. 


FIG.  266. — Same  soecimen.     Shows  this  same  condition  more  clearly. 

mass  as  presented  to  the  cystoscopist  and  judged  by  the  eye,  and  the 
mass  as  found  in  situ  at  the  time  of  operation  and  appreciated  by  the 


ENLARGEMENT  OF  PROSTATE 


575 


finger;  second,  a  careful  determination  of  the  prostatic  mass  in  relation 
to  the  opening  of  the  urethra  and  the  sphincter  vesicse;  and  third,  a 
thorough  gross  and  sectional  examination  of  all  our  specimens  after 
removal  by  the  transvesical  route. 


FIG.  267. — Specimen  removed  by  transvesical  operation,  showing  under  surface  in  a  case 
of  enlargement  of  both  lateral  lobes. 


FIG.  268. — Same  specimen  as  Fig.  267.  The  anterior  commissure  divided,  showing 
two  lateral  hypertrophied  lobes  and  the  normal-sized  median  lobe  joining  the  two 
enlarged  lobes. 

ENLARGEMENT  OF  PROSTATE. 

Occurrence. — In  any  large  series  of  cases  of  prostatic  enlargements 
about  80  per  cent,  will  be  found  to  be  due  to  non-malignant  hyper- 


576  PROSTATIC  OBSTRUCTIONS 

plasia  of  the  gland  elements.  We  seldom  find  true  enlargements  of 
the  prostate  in  men  under  fifty  years  of  age,  the  majority  of  cases 
coming  to  the  surgeon  for  treatment  between  the  ages  of  sixty  and 
seventy-five  years.  Various  estimates  have  been  made  as  to  the 
frequency  of  enlargements  of  the  prostate,  the  consensus  of  opinion 
being  that  it  occurs  in  about  30  to  35  per  cent,  of  all  males  over  sixty 
years  of  age.  It  is  impossible  to  say  how  many  of  these  have 
obstructive  symptoms. 

The  most  frequent  form  of  enlargement  is  the  large,  soft  type 
which  is  produced  by  a  hyperplasia  of  both  the  parenchyma  and  the 
stroma. 

Hypertrophy  due  to  hyperplasia  of  the  stroma  alone  occurs  in  about 
5  per  cent,  of  the  cases,  and  in  the  Mayo  series  20  per  cent,  of  the  cases 
showed  an  increase  in  the  parenchyma  without  apparent  increase  of 
the  stroma. 

Etiology. — Concerning  this  we  know  very  little.  All  are  agreed  that 
the  true  hyperplasia  of  the  gland  elements  is  not  the  result  of  inflamma- 
tion. On  the  other  hand,  it  is  the  writer's  belief  that  many  of  the 
deformities  of  the  prostate  where  there  is  no  true  cytoplasia  are  the 
results  of  inflammation. 

From  a  study  of  many  prostates  it  has  seemed  to  us  that  in  the 
majority  of  cases  the  enlargements  were  due  more  to  glandular  over- 
growth, distorted  and  increased  by  the  degenerative  changes  of  old  age, 
than  to  the  influence  of  any  extrinsic  inflammatory  agency  constricting 
the  ducts  and  causing  their  dilatation.  The  question  may  be  asked 
why  this  does  not  take  place  in  all  cases.  That  is  as  difficult  to  answer 
as  it  is  to  explain  why  fibroids,  myomata  and  adenomata  develop  in  the 
uterus  of  one  woman  and  not  in  that  of  another.  We  believe  that  it  is 
not  necessarily  the  length  of  functional  activity  of  the  gland  and  the 
age  of  the  individual  which  cause  this  change,  but  that  it  is  a  glandular 
overgrowth  influenced  by  the  degenerative  changes  of  old  age  in  an 
actively  functionating  gland  which  produces  the  change.  A  previous 
gonorrheal  infection,  or  any  other  inflammatory  process,  may  influence 
the  development  of  the  disease. 

It  is  but  fair  to  suppose,  too,  that  other  causes  may  influence  this 
overgrowth.  Excessive  venery,  overindulgence  in  alcohol,  masturba- 
tion, protracted  habit  of  withdrawal,  sexual  excesses,  perverted 
indulgences,  horseback  riding,  long-continued  sedentary  habits,  con- 
stipation and  climatic  exposures,  all  may  be  considered  as  possible 
contributing  etiological  factors. 

Changes  in  the  Urethra. — The  prostatic  urethra  is  distorted,  depend- 
ing upon  the  size,  direction  and  extent  of  the  hypertrophy.  It  affects 
that  portion  of  the  urethra  between  the  verumontanum  and  the  orifice 
of  the  bladder.  It  is  elongated  and  compressed,  its  plane  depressed 
downward  and  backward,  and  it  frequently  is  tortuous.  WThen  the 
lateral  lobes  are  greatly  enlarged  the  urethra  appears  as  a  mere  cleft 
between  the  two  lobes  (Fig.  269).  The  internal  orifice  of  the  urethra 
may  assume  almost  any  form,  depending  on  the  character  of  the  enlarge- 


ENLARGEMENT  OF  PROSTATE 


577 


ments.  The  mucous  membrane  of  the  urethra  is  intimately  related  to 
the  gland  itself  and  can  only  be  separated  from  it  with  difficulty. 
(Fig.  270.) 


FIG.  269.— Horizontal  section  of  prostate  removed  by  suprapubic  prostatectomy, 
"total"  enucleation  showing  carcinoma  along  with  chronic  lobular  prostatitis  (prostatic 
hypertrophy),  and  portion  of  prostatic  sinus  adherent.  (Wade.) 


FIG.  270.— Showing  intimate  relation  between  urethral  mucous  membrane  and  gland. 

Secondary  Changes  in  the  Urinary  Organs.— These  are  due  primarily 
to  obstruction  at  the  outlet  of  the  bladder  and  later  to  infection. 


M  u     i — 37 


578  FROST  AT  1C  OBSTRUCTIONS 

Deformity  at  the  outlet  of  the  bladder  involving  also  the  trigonum 
corresponds  to  the  extent  and  direction  of  the  hypertrophy  of  the  pros- 
tate. As  a  rule  the  gland  enlarges,  forces  its  way  through  the  sphincter 
vesicse,  gradually  dilating  it.  In  the  cases  of  massively  hypertrophied 
gland  the  sphincter  is  so  widely  dilated  that  it  becomes  functionless. 
At  the  same  time  the  urethral  orifice  is  raised,  being  displaced  by  the 
enlarging  gland.  Its  form  depends  upon  the  character  of  the  glandular 
hyperplasia,  especially  the  size  and  shape  of  the  middle  lobe. 

In  the  cases  where  the  prostate  is  small  and  fibrous  the  orifice  is 
displaced  less,  but  the  opening  is  much  less  flexible,  as  is  true  also  of 
the  cases  of  bar  formation.  In  all  of  these  cases  the  orifice  is  held  high 
up  and  the  trigonum  drops  down  nearly  vertically,  so  that  the  bladder 
tends  to  sag  at  this  point  and  form  a  so-called  pouch  below  the  level 
of  the  orifice,  which  makes  it  difficult  to  entirely  empty  the  bladder. 
The  increasing  obstruction  in  the  urethra,  the  lack  of  flexibility  of  the 
sphincter,  the  unnatural  high  position  of  the  orifice  and  the  sagging 
posterior  wall  of  the  bladder,  all  favor  incomplete  emptying  of  the 
bladder  which  gradually  results  in  urinary  stasis  of  varying  degrees, 
influenced  by  the  changing  condition  of  the  prostate.  Retention  of 
urine  produces  its  own  train  of  symptoms  and,  as  the  amount  increases, 
the  pathological  changes  extend,  affecting  the  bladder  itself,  the  ureters, 
the  kidney  and  finally  the  general  system.  (Plate  VII.) 

The  bladder  is  affected  first.  The  obstruction  to  the  outflow  of  urine 
is  partially  compensated  for  by  an  increase  in  the  thickness  and  strength 
of  the  muscular  walls.  The  muscle  bands  increase  very  markedly  in 
size  and,  as  the  obstruction  increases,  the  individual  muscle  columns 
hypertrophy  to  such  an  extent  that  they  stand  out  on  the  inner  wall  of 
the  bladder,  forming  an  interlacing  network  of  bands  or  trabeculations. 
As  the  obstruction  increases  and  the  force  exerted  continues,  the  section 
of  the  bladder  wall  between  the  muscle  bands  bulges  and  numerous 
false  diverticula  are  produced.  The  ureter  openings  are  usually  not 
affected  until  a  late  stage  of  the  disease.  With  the  incidence  of  infection, 
the  mucous  membrane  becomes  inflamed,  mucus  and  phosphatic  mate- 
rial deposits  between  the  trabeculse  and  calculi  form.  In  our  own 
series  calculi  were  found  in  about  20  per  cent,  of  the  cases.  If  the 
cystitis  is  of  long  standing,  the  inflammation  extends  more  deeply 
into  the  bladder  wall  and  further  impairs  its  utility. 

The  ureters  and  finally  the  kidneys  gradually  become  affected,  first 
from  mechanical  obstruction  and  second  through  infection. 

Aside  from  the  clinical  evidence  of  renal  infection  and  renal  insuf- 
ficiency, the  most  striking  evidence  of  renal  injury  due  to  prostatic  ob- 
struction is  presented  in  those  patients  dying  from  the  disease.  Autopsy 
shows  a  variety  of  conditions  existing  in  the  kidney,  the  lesion  most 
common  to  all  being  a  dilatation  of  the  ureter  beginning  immediately 
above  the  bladder,  resulting  in  various  degrees  of  hydro-ureter  and 
hydronephrosis  and  destruction  of  the  kidney  parenchyma.  This  in 
turn  is  influenced  by  the  degree  and  duration  of  the  obstruction  and  in 
more  advanced  cases  is  accompanied  by  infection,  formation  of  renal 


PLATE   VII 


Extreme  Backward  Pressure  Produced  by  Prostatic 
Hypertrophy. 

Note  extreme  dilatation  of  both  ureters  and  renal  pelves  and  extreme 
atrophy  of  renal   secreting  tissue.      (Wade.) 


ENLARGEMENT  OF  PROSTATE  579 

calculi,  and  in  some  by  actual  infection  and  destruction  of  the  kidney 
parenchyma. 

Urinary  Obstruction  without  Enlargement  of  the  Prostate. — This 
subject  should  occupy  a  chapter  by  itself,  but  is  so  closely  allied  with 
the  subject  of  enlargements  of  the  prostate  that  it  must  be  mentioned 
here.  We  recognize  a  number  of  lesions  entirely  distinct  in  etiology 
and  histological  formation. 

First  Type. — A  submucous  fibrosis.  The  most  prominent  change 
found,  according  to  Young,  is  the  occurrence  of  a  newly  formed  con- 
nective-tissue layer  immediately  beneath  the  mucous  membrane, 
forming  a  firm  fibrous  ring  associated  with  an  elevation  of  the  median 
portion  of  the  prostate.  There  is  no  underlying  prostatitis,  no  infiltra- 
tion of  the  sphincter  muscle,  or  hyperplasia  of  gland  tissue.  It  is 
essentially  a  submucous  fibrosis. 

Second  Type. — Hardly  less  frequent  are  those  cases  of  deformed 
orifice  due  to  chronic  inflammatory  change  in  the  glandular  tissue  with 
round-cell  infiltration  occasionally  extending  into  the  muscle.  This 
is  undoubtedly  due  to  previous  prostatitis. 

Third  Type. — That  due  to  hypertrophy,  or  proliferation  of  the  sub- 
urethral  or  subtrigonal  group  of  gland  acini.  This  produces  retention 
by  mechanical  obstruction  precisely  as  do  enlargements  of  the  prostate. 

Symptoms. — The  most  characteristic  symptom  of  obstructive  pros- 
tatic  disease  is  the  gradual  development  of  frequent  urination,  with  a 
gradually  increasing  urgency  of  urination,  and  in  many  cases  an 
increase  in  the  amount  of  urine  passed. 

Around  these  symptoms  are  grouped  various  classes  of  cases  which 
may  be  described  as  different  types,  nearly  all  of  which  either  early  in 
the  disease,  or  later,  present  the  symptom  of  frequency  of  urination  as 
its  most  prominent  feature. 

It  has  been  the  writer's  experience  that  the  particular  symptom- 
complex  is  not  dependent  upon  any  one  form  of  prostatic  enlargement. 
Naturally,  the  symptoms  are  dependent  upon  the  degree  of  pathological 
change  present  along  the  urogenital  tract.  Nephritis,  pyelonephritis, 
stone  in  the  kidney,  ureter,  or  bladder,  purulent  cystitis,  diverticulitis, 
increasing  degrees  of  residual  urine,  all  influence  the  symptom-complex. 
Stone  in  the  bladder  especially  affects  the  symptoms,  for  its  presence 
causes  a  congestion  and  pseudo-enlargement  of  the  prostate,  the 
obstruction,  however,  decreasing  upon  the  removal  of  the  stone. 

The  primary  symptoms  are  due  chiefly  to  the  obstruction  to  urination 
caused  by  the  changes  in  and  about  the  prostate,  and  in  addition  to 
congestion  of  the  mucous  membrane  and  morphological  irregularities 
in  the  prostatic  portion  of  the  urethra.  Frequency  and  urgency  of 
urination  are  dependent  on  these  factors,  while  the  symptoms  of  painful 
urination  and  distress  after  urinating  usually  are  associated  with 
inflammatory  conditions  of  the  prostate  and  the  more  infrequent  forms 
of  obstruction  due  to  fibrous  hyperplasia. 

The  usual  story  is  that  of  increasing  frequency  of  urination,  first 
noticed  at  night;  later  a  certain  amount  of  urgency  when  the  desire  to 


580  PROSTATIC  OBSTRUCTIONS 

urinate  is  present;  slight  difficulty  in  starting  the  stream,  some 
diminution  in  the  force  and  size  of  the  stream  as  it  is  ejected ;  a  certain 
amount  of  distress  in  the  perineum ;  also,  under  stress  of  nervous  excite- 
ment, or  after  exposure  to  cold,  there  is  often  a  marked  inability  to 
urinate  voluntarily,  and  the  impossibility  of  checking  the  stream  as 
quickly  and  fully  as  was  formerly  possible.  The  symptoms  are  quite 
irregular  as  a  rule,  there  being  periods  of  well-being  during  which  time 
the  patient  does  not  notice  anything  unusual  other  than  the  slight 
increased  frequency  of  urination,  and  again,  the  symptoms  will  be 
increased  by  various  indiscretions  of  diet  or  exercise,  and  there  will 
exist  considerable  difficulty  in  urinating  and  a  sense  of  pressure  and 
incomplete  evacuation  of  the  bladder  with  more  or  less  continued  desire 
to  urinate  after  the  act  has  been  completed.  Even  in  the  early  stage 
we  may  have  a  period  of  temporary  complete  retention  of  urine  coming 
on  after  undue  exposure.  This  may  last  for  a  few  days  and  then  pass 
off  entirely.  If  the  obstruction  is  due  to  an  irregular  form  of  enlarge- 
ment, such  as  a  submucous  fibrosis  or  small  nodular  hyperplasia,  with 
only  partial  obstruction  of  the  canal,  we  usually  have  in  addition  to  the 
ordinary  symptoms  vague  pains  referred  to  the  perineum,  to  the  back 
and  to  the  legs,  and  in  addition  painful  urination.  If  at  any  time  a 
catheter  is  used,  infection  may  take  place  and  the  entire  picture  may 
change  to  one  of  cystitis  with  urinary  stasis.  Later  in  the  early  stage 
there  may  be  enuresis  and  slight  dribbling  of  urine  during  the  day.  At 
a  later  period  in  the  development  of  the  enlargement  the  symptoms  are 
mostly  those  of  obstruction  and  pressure,  with  the  symptoms  localized 
in  the  bladder  and  urethra.  It  is  a  period  of  incomplete  chronic 
retention.  The  bladder  at  no  time  is  entirely  empty  unless  a  catheter  is 
passed.  The  urine  frequently  does  not  change  its  character  except 
in  the  lowering  of  the  specific  gravity  and  an  increase  in  the 
actual  amount  of  the  urine  passed.  The  symptoms  here  are  variable, 
depending  upon  the  amount  of  dilatation  of  the  bladder.  There  is  an 
increase  in  the  dysuria,  the  urinary  stream  is  smaller  and  it  may  even 
decrease  in  size  until  the  patient  urinates  intermittently  in  very  small 
amounts.  Dull  pain  in  the  bladder  region  extending  downward  to  the 
legs  is  frequently  complained  of  at  this  stage  of  the  disease.  There  is 
some  difficulty  at  stool  and  the  patient  begins  to  strain  and  exert  con- 
siderable muscular  effort  to  empty  his  bladder.  During  this  period  of 
mechanical  obstruction,  calculi  frequently  form  in  the  bladder.  In  our 
own  series  of  cases  it  occurred  in  about  20  per  cent,  of  the  cases.  The 
calculus  tends  to  increase  the  disturbing  symptoms  and  invites  infection. 
At  this  time  also,  secondary  changes  begin  to  take  place  in  the  kidney 
and  the  reflex  disturbances  make  their  appearance,  especially  those  of 
the  gastro-intestinal  tract.  Hematuria  may  occur  at  any  time,  but  is 
evidence  of  either  a  complication  or  an  advanced  stage  of  hyperplasia. 
The  kidney  becomes  more  and  more  affected  by  the  chronic  retention 
and  expresses  itself  in  an  increased  secretion  of  urine  of  a  low  specific 
gravity.  In  addition,  changes  in  the  stability  of  the  renal  function 
become  evident. 


ENLARGEMENT  OF  PROSTATE  581 

The  patient's  general  condition  begins  to  suffer  markedly.  There 
are  evidences  of  loss  of  sleep,  the  loss  of  appetite,  lack  of  food  and 
increasing  mental  unbalance  resulting  in  a  condition  of  chronic  inva- 
lidism.  The  patient  becomes  an  object  of  pity,  his  linen  is  saturated 
with  urine  and  he  always  carries  with  him  the  unmistakable  odor  of 
decomposing  urine.  Gradually  as  time  goes  on  his  entire  attention  is 
given  to  emptying  his  bladder.  If  the  case  still  remains  untreated,  the 
patient  passes  on  to  a  stage  of  chronic  complete  retention  of  urine  with  a 
guttatim  overflow.  The  constant  straining  often  produces  inguinal 
hernise,  hemorrhoids  and  prolapsus  ani.  Efforts  to  empty  the  bladder 
become  more  and  more  ineffectual  and  the  use  of  a  catheter  is  resorted 
to.  Sooner  or  later  cystitis  develops  which  adds  its  distressing  symp- 
toms. Later  the  ureters  and  kidneys  share  in  the  infection  and  death 
results. 

The  complications  and  sequellse  of  infection  and  calculus  formation 
along  the  urinary  tract  are  the  same  in  their  terminal  stage,  whether  due 
to  prostatic  obstruction  or  to  other  obstruction  in  the  urethra,  or  at  the 
neck  of  the  bladder. 

It  is  impossible  to  give  a  complete  word  picture  of  the  symptoma- 
tology of  this  disease  because  of  the  diversity  of  the  pathological 
changes  which  take  place.  For  example,  some  patients  will  present 
symptoms  of  the  early  stages  of  the  disease  and  remain  without  change 
for  years,  while  other  patients  will  rapidly  pass  from  one  stage  to  the 
other  and  unless  properly  treated  will  find  their  lives  intolerable  in  a 
short  period  of  time.  It  is  well  known,  also,  that  some  men  will  go 
about  suffering  from  a  chronic  overdistention  of  the  bladder  without 
ever  having  suffered  urinary  symptoms  to  call  their  attention  to  the 
fact. 

The  main  features,  however,  are  the  same.  That  is,  the  gradual 
development  of  an  obstruction  at  the  outlet  of  the  bladder,  causing 
incomplete  evacuation  of  the  urine,  resulting  in  far-reaching  patho- 
logical changes,  and  terminating  in  death  from  uremia  or  sepsis. 

Diagnosis. — History. — It  is  important  hi  every  case  to  take  a  com- 
plete history  of  the  patient.  This  includes  the  usual  data  concerning  the 
early  life  and  habits  of  the  patient,  as  well  as  a  detailed  record  of  the 
diseases  and  accidents  suffered  by  him.  The  special  points  worthy  of 
note  in  all  patients  suffering  from  urinary  disturbances  have  already 
been  stated  in  previous  chapters.  In  these  cases  we  wish  to  know  first 
the  age  of  the  patient,  his  social  status,  his  venereal  history  and  whether 
or  not  he  has  at  any  time  suffered  from  infection  of  the  kidney  or 
bladder,  has  passed  calculi,  or  has  been  subject  to  attacks  of  renal  colic. 
We  should  ascertain,  if  possible,  whether  pus  or  blood  has  ever  been 
found  in  his  urine.  It  is  especially  important  to  know  if  there  have 
ever  been  any  periods  when  he  was  unable  to  voluntarily  evacuate  his 
bladder.  If  so,  has  it  been  necessary  to  pass  sounds  or  catheters  to 
withdraw  the  urine?  In  fact,  it  is  always  best  to  obtain  all  the  data 
possible  concerning  the  urinary  organs  of  the  patient  previous  to  his 
present  trouble. 


582 


PROSTATIC  OBSTRUCTIONS 


Next,  it  is  important  to  question  the  patient  concerning  the  develop- 
ment of  the  disorder  for  which  he  seeks  relief.  The  duration  of  his 
symptoms,  the  order  of  their  occurrence,  the  extent  of  the  disability 
resulting,  and  the  eft'ect  upon  other  organs  and  systems  of  the  body. 
Usually  the  patient's  attention  will  centre  about  the  act  of  urination, 
the  increasing  frequency  at  night  and  during  the  day,  the  difficulty  of 
starting  the  stream,  the  smallness  of  the  stream  and  the  lack  of  force  in 
ejecting  it,  and  the  soiling  of  his  linen  afterward.  Such  a  history 
given  by  a  man  of  advanced  years  immediately  makes  one  think  that  he 
is  suffering  from  obstructive  enlargement  of  the  prostate.  Tnere  are, 
however  a  number  of  other  pathological  lesions  which  may  give  rise  to 
these  same  symptoms.  Therefore  a  detailed  history  should  be  taken 
and  a  careful  examination  of  the  patient  made. 


The  sof  t-rubber  catheter. 


Mercier  coud6  catheter. 


Mcrcit-r  bicoiuU'-  c:iihcfcr. 


Bougie  catheters. 
FIG.  271. — Various  forms  of  catheters. 

Examination. —  A  general  physical  examination  of  the  patient  should 
first  be  made.  It  is  unnecessary  to  reiterate  the  details  of  this  pro- 
cedure, but  special  care  should  be  directed  to  the  condition  of  the  lungs 
and  heart  and  the  general  arterial  a  nd  venous  systems.  It  is  important 
to  know  the  condition  of  the  heart  muscle  and  the  condition  of  the 
walls  of  the  arteries;  and  in  addition,  to  record  the  blood-pressure.  An 
examination  of  the  blood  should  be  made  to  ascertain  the  percentage  of 
hemoglobin  which  is  present,  and  to  determine  when  possible,  the  bl<  >od 
urea  and  blood  creatinin  content  as  an  index  of  the  renal  efficiency. 


ENLARGEMENT  OF  PROSTATE  583 

A  detailed  examination  of  the  abdomen  should  be  made,  noting 
especially  the  condition  of  the  stomach  and  intestines,  palpating  for 
tumors,  and  percussing  for  the  bladder,  if  it  is  distended.  Frequently 
the  examiner  will  note  the  presence  of  inguinal  hernia?. 

Next,  the  legs  are  examined,  searching  especially  for  edema  and 
varicosities. 

With  a  knowledge  of  the  general  condition  of  the  patient,  the  phy- 
sician then  turns  to  an  examination  of  the  urethra  and  bladder.  At  this 
point  a  divergence  of  opinion  arises.  The  expert  in  urethral  catheterism 
needs  no  advice.  The  ordinary  physician  is  advised  to  use  the  instru- 
ments which  can  do  the  least  harm.  The  writer  has  devised  for  his  own 
use  a  metal  instrument  with  a  short  beak,  number  18  of  the  French 
scale  in  size,  with  a  well-curved  smooth  beak,  fitted  with  an  electric 
lamp  and  observation  telescope,  which  he  uses  to  explore  the  urethra 
and  observe  the  interior  of  the  bladder,  and  study  the  conformation  of 
the  prostate.  With  this  simple  instrument  he  sounds  the  urethra, 
determines  the  presence  of  residual  urine,  and  obtains  all  the  informa- 
tion necessary  in  the  majority  of  cases.  The  technic  for  using  this 
instrument  is  given  later.  If  one  is  not  experienced  in  the  use  of  a 
cystoscope,  it  is  wiser  to  employ  the  older  methods  of  diagnosis,  pref- 
erably a  medium-sized  soft-rubber  catheter,  or,  if  this  cannot  be  passed, 
a  Mercier  coude  catheter  which  is  stiffer  and  is  especially  molded  so 
that  the  end  tends  to  pass  up  over  the  obstructing  prostate  and  enters 
the  bladder.  If  one  is  not  successful  with  the  Mercier  coude  catheter, 
the  bicoude  or  the  bougie  catheters  should  be  tried  (Fig.  271). 

Another  useful  instrument  is  the  well-curved  metal  catheter  made  of 
German  silver. 

The  operator  must  employ  every  precaution  to  protect  the  urethra 
and  bladder  from  infection. 

Technic. — The  patient  first  passes  as  much  urine  as  possible.  Then 
with  the  patient  in  the  recumbent  position,  the  glans  penis  is  carefully 
cleansed,  the  instrument  lubricated  and  introduced  slowly.  Great  care 
must  be  exercised  when  the  prostatic  urethra  is  reached.  Too  great 
force  exerted  at  this  point  will  easily  cause  laceration  of  the  tissues 
which  causes  hemorrhage  and  invites  infection.  If  the  obstruction 
cannot  be  overcome  after  trying  various  catheters,  the  operator  should 
desist.  The  beginner  should  be  warned  against  using  small,  stiff  in- 
struments for  two  reasons.  First,  they  are  more  apt  to  cause  injury, 
and  second,  because  a  large  one  usually  passes  more  easily  into  the 
bladder. 

If  the  catheter  enters  the  bladder,  the  urine  is  allowed  to  flow  out. 
If  the  bladder  is  overdistended ,  it  should  nerer  be  entirely  emptied,  as  fatal 
hemorrhage  into  the  bladder  has  been  known  to  follow  this  procedure. 
The  amount  of  urine  withdrawn  (after  the  patient  has  passed  as  much 
as  he  could  voluntarily)  constitutes  the  residual  urine.  This  is  saved 
for  laboratory  examination.  Before  withdrawing  the  catheter  it  is  well 
to  introduce  an  ounce  of  sterile  olive  oil  or  gomenol,  or  a  small  amount 
of  argyrol  into  the  bladder  and  allow  it  to  remain. 


584  PROSTATIC  OBSTRUCTIONS 

During  the  passage  of  the  catheter  or  metal  instrument  through  the 
prostatic  urethra,  the  length  of  this  portion  of  the  tract  can  usually 
be  estimated  and  frequently  its  tortuosity  can  be  appreciated. 

Rectal  Examination. — This  is  always  of  importance.  The  finger  in 
the  rectum  will  easily  detect  any  marked  enlargement  of  the  lateral 
lobes.  If  malignant  disease  exists,  it  is  usually  most  marked  in  the 
posterior  lobe,  and  one  feels  varying  degrees  of  induration  and  hardness 
here  which  leads  one  at  least  to  suspect  cancer.  Often  intravesical 
enlargements  of  the  prostate  are  present  which  cannot  be  determined 
by  the  finger. 

The  Use  of  the  Cystoscope. — No  instrument  which  has  been  devised  for 
estimating  the  size,  conformation,  and  relations  of  a  diseased  prostate 
has  proved  more  useful  than  the  simple  prismatic  or  correct-vision 
cystoscope  in  the  hands  of  an  experienced  operator. 

The  cystoscope  is  quite  accurate  for  determining  the  size  and  contour 
of  an  intravesically  hypertrophied  prostatic  lobe.  The  thickness  of  an 
intravesical  glandular  hyperplasia  may  be  measured,  and  the  prostatic 
urethra  may  be  explored. 

For  these  uses  it  is  necessary  to  have  an  instrument  in  which  the 
reflecting  prism  is  so  constructed  that  objects,  even  though  they  may  be 
almost  touching  the  surface  of  the  prism,  may  be  distinctly  seen.  One 
must,  however,  always  make  proper  allowance  for  the  magnification 
and  possible  distortion.  For  special  use  in  cases  of  prostatic  hyper- 
trophy the  writer  has  devised  a  cystoscope  the  curve  of  which  resembles 
that  of  an  ordinary  sound.  There  are  no  sharp  angles  and  the  instrument 
is  easy  of  introduction  into  the  bladder.  In  fact,  it  is  often  possible  to 
pass  this  instrument  into  the  bladder  in  cases  of  prostatic  hypertrophy 
even  when  a  catheter  cannot  be  introduced.  In  the  ordinary  case,  in 
order  to  complete  our  examination,  we  first  have  the  patient  pass  his 
urine  and  then  we  immediately  introduce  the  small  bladder  cystoscope, 
measure  the  residual  urine,  wash  out  the  bladder  through  the  cysto- 
scope, reintroduce  the  telescope,  and  make  a  further  examination  of  the 
bladder.  The  essential  points  in  the  technic  of  the  examination  are  as 
follows: 

Technic. — The  anterior  urethra  is  made  insensitive  by  the  use  of  a 
4  per  cent,  novocain  solution.  If  the  patient  is  supersensitive,  two 
grains  of  alypin  are  deposited  in  the  posterior  urethra.  The  bladder 
cystoscope  is  then  introduced  as  previously  described.  The  bladder  is 
filled  with  200  to  500  c.c.  of  sterile  water,  or  a  2  per  cent,  boric  acid 
solution,  and  a  thorough  examination  is  made. 

Conducting  the  Examination.— The  base  of  the  bladder  and  the  ureter 
openings  are  first  examined.  This  is  essential,  because  there  is  fre- 
quently some  bleeding  caused  by  the  instrumentation  and  the  base  of 
the  bladder  becomes  quickly  obscured.  The  urinary  efflux  is  studied, 
diverticula,  calculi,  tumors,  scars,  and  other  pathological  conditions 
looked  for,  especially  noting  the  presence  and  degree  oftrabeculation.  This 
will  give  some  idea  of  the  effect  of  the  obstruction  on  the  bladder. 
Sometimes  we  find  distortion  of  the  ureter  openings,  but  there  is  seldom 


ENLARGEMENT  OF  PROSTATE  585 

interference  with  the  urinary  efflux  unless  the  disease  has  progressed  to 
the  stage  of  involvement  of  the  ureter  and  kidney.  Diverticula  occur 
most  frequently  near  the  ureter  openings  and  at  the  vertex  of  the 
bladder.  If  there  is  an  insufficient  quantity  of  fluid  in  the  bladder, 
the  base  sinks  down  and  it  is  difficult,  and  often  impossible,  to  examine 
thoroughly  the  pouch  which  is  formed  below  the  prostatic  bar  or  median 
enlargement  of  the  prostate.  This  difficulty  may  be  overcome  by  intro- 
ducing more  fluid,  which  will  tend  to  elevate  the  base  of  the  bladder  so 
that  the  trigone  will  come  more  fully  into  view.  It  is  in  this  pouch, 
which  forms  mainly  posterior  to  the  interureteric  band,  that  phosphatic 
concretions,  diverticula,  and  stones  are  found. 

As  a  result  of  chronic  obstruction  the  muscular  structure  of  the 
bladder  wall  becomes  greatly  hypertrophied  and  thickened.  In  the 
earlier  stages  of  prostatic  obstruction  only  a  few  of  these  bundles  are 
seen  crossing  the  wall;  but  as  the  obstruction  becomes  more  complete 


FIG.  272. — Cystoscopic  picture  showing  false  diverticula  in  a  trabeculated  bladder — the 

result  of  disease. 


they  appear  as  innumerable,  well  developed,  interlacing  columns, 
resembling  a  lattice-work,  with  larger  and  smaller  branches,  much  like 
the  muscular  structure  seen  on  the  inside  of  the  ventricles  of  the  heart 
(Fig.  272).  The  spaces  between  these  bundles  frequently  show  the 
openings  of  diverticula,  which  vary  greatly  in  size  and  depth ;  some- 
times stones  are  found  within  them.  Such  pockets,  when  infected, 
give  rise  to  an  intractable  cystitis.  The  superior  surface  and  sides  of 
the  bladder  do  not  share  equally  with  the  posterior  surface  in  this 
change. 

In  many  cases  of  prostatic  disease  there  is  present  in  the  bladder  some 
evidence  of  inflammation.  It  varies  from  a  simple  hyperemia  of  the 
base  to  a  severe  general  involvement  of  the  viscus.  In  the  chronic 
forms  the  mucous  membrane  is  swollen  and  pale;  with  acute  exacerba- 
tions portions  of  the  bladder  appear  more  acutely  inflamed,  especially 
the  trigone,  but,  as  a  rule,  the  rest  of  the  bladder  remains  unchanged. 


586  PROSTATIC  OBSTRUCTIONS 

This  naturally  depends  upon  the  intensity  of  the  cystitis.  In  the  old 
chronic  forms  the  bladder  will  be  found  covered  with  shreds  of  muco- 
pus  and  phosphatic  concretions  which  are  difficult  to  detach.  If  a 
stone  of  large  size  is  present,  a  satisfactory  examination  cannot  always 
be  made. 

Examination  of  the  Prostate. — It  must  be  remembered  that  in  using 
the  ordinary  prismatic  cystoscope,  without  the  correct-view  lens,  the 
picture  seen  is  inverted  and  considerably  magnified.  The  newer  lenses 
give  a  correct  view  with  a  magnified  picture. 

As  the  instrument  is  drawn  back  toward  the  urethra,  after  a  thorough 
examination  of  the  bladder  has  been  made,  the  prostate  will  come  into 
view  and  that  portion  of  the  organ  covered  by  bladder  mucosa  can  be 
carefully  studied.  Only  a  small  portion  can  be  viewed  at  one  time. 
The  operator  should  first  view  the  entire  orifice  by  turning  the  cysto- 
scope through  a  complete  circle.  This  gives  an  idea  of  the  prostatic 
mass;  any  abnormalities  may  be  noted,  to  be  studied  later  in  detail. 
The  size  and  position  of  the  median  enlargement  and  its  relation  to  the 
trigone  and  the  ureter  openings  should  be  studied. 

The  normal  prostatic  orifice  appears  circular  except  at  its  posterior 
margin,  which  is  flattened  or  slightly  raised. 

In  bilateral  enlargement  of  the  prostate  the  anterior  and  posterior 
views  show  sulci  of  varying  depths.  As  the  instrument  is  turned 
around,  the  lateral  lobes  are  seen  to  come  together  and  project  into  the 
bladder. 

In  marked  median-lobe  enlargement  the  position  of  the  cystoscope  as 
it  enters  the  bladder  may  be  so  influenced  that  it  will  lie  in  a  sulcus 
between  the  median  lobe  and  a  lateral  lobe,  and  it  is  only  by  raising  or 
depressing  the  shaft  of  the  instrument  that  a  correct  idea  of  the  true 
conditions  can  be  obtained. 

The  picture  presented  by  a  cleft  formed  by  two  hypertrophied  lobes 
depends  upon  the  position  of  the  cystoscope.  If  the  cystoscope  is 
pressed  up  into  the  sulcus,  the  lobes  are  separated  and  no  cleft  is  seen. 
But  as  the  beak  is  lowered,  the  lobes  press  together  and  the  cleft  can  be 
seen. 

In  this  way  the  prostatic  orifice  may  be  studied,  and  a  fairly  exact 
idea  of  the  degree  and  character  of  the  prostatic  enlargement  be 
obtained. 

Of  what  Value  is  the  Cystoscope  in  the  Diagnosis  of  Obstructive  Pros- 
tatic Hypertrophy? — By  the  use  of  the  instrument  all  the  necessary 
intra-urethral  instrumentation  can  be  carried  out;  the  presence  of 
strictures  determined;  the  length  of  the  urethra  measured ;  the  amount 
of  resistance  in  the  prostatic  urethra  accurately  felt  by  the  hand ;  the 
amount  of  residual  urine  measured,  and,  in  the  great  majority  of  cases, 
the  presence  of  new  growth  or  other  obstructing  intravesical  conditions 
be  excluded.  The  presence  or  absence  of  a  calculus  is  always  important 
to  know  beforehand,  and  this  can  be  diagnosed  with  the  greatest 
accuracy  by  the  cystoscope.  Oftentimes  the  presence  of  a  stone  in  the 
bladder  will  cause  sufficient  congestion  of  a  prostate  to  create  obstruc- 


ENLARGEMENT  OF  PROSTATE  587 

tion.  Furthermore,  the  exact  position  of  the  obstructing  mass,  be  it -a 
prostatic  bar  or  a  single  ball-valve  median-lobe  enlargement,  or  a  lateral- 
lobe  encroachment,  or  an  anterior-lobe  obstruction,  may  all  be  deter- 
mined before  operation  is  undertaken.  This  knowledge  may  have  an 
important  bearing  upon  the  character  of  the  operation. 

Before  withdrawing  the  cystoscope  the  lamp  should  be  extinguished, 
and  with  the  instrument  still  in  the  bladder  and  one  finger  in  the  rectum 
the  thickness  of  the  prostatic  bar  can  be  determined  by  drawing  the 
beak  of  the  instrument  down  and  engaging  the  prostatic  urethra 
between  it  and  the  examining  finger. 

Dangers  of  Cystoscopy  in  Hypertrophy  of  the  Prostate. — Fenwick 
states  very  positively  that  no  patient  over  forty-five,  suffering  from 
nocturnal  incontinence,  great  thirst,  and  morning  nausea,  should  be 
subjected  to  cystoscopy.  Fortunately,  this  combination  of  symptoms 
is  rare.  In  cases  where  there  is  an  enormous  enlargement  of  the  gland, 
cystoscopy  is  not  necessary,  but  is  not  dangerous.  The  chief  danger 
arises  from  rough  handling  and  forcing  the  instrument  through  the 
prostatic  urethra  when  there  is  great  resistance.  The  obstruction  can 
usually  be  passed  by  depressing  the  ocular  end  of  the  instrument.  One 
needs  simply  to  use  the  same  precautions  employed  in  any  urethral 
catheterism. 

X-ray  Examination. — This  is  seldom  employed  as  a  routine  method  of 
examination  in  the  diagnosis  of  urinary  obstruction.  It  is  of  value, 
however,  in  those  cases  where  the  diagnosis  is  doubtful,  especially  where 
we  know  or  suspect  that  a  stone  is  present  in  the  bladder.  Occasionally 
a  calculus  is  hidden  in  a  diverticulum,  and  the  ordinary  examination 
with  the  finger  does  not  always  discover  it.  Frequently  there  are  small 
stones  which  form  in  the  substance  of  the  prostate,  but  it  has  been  our 
experience  that  they  do  not  always  register  on  the  x-ray  plate. 

The  x-ray  examination  is  especially  valuable  in  the  cases  in  which 
there  is  a  recurrence  of  the  dysuria  following  prostatectomy.  The  pic- 
tures are  taken,  first  with  the  bladder  empty  and  second  with  the  bladder 
filled  with  an  opaque  solution.  The  presence  of  calculi,  diverticula, 
and  irregularities  at  the  outlet  of  the  bladder  can  sometimes  be 
demonstrated. 

How  Far  are  We  Justified  in  Insisting  on  a  Complete  Diagnosis 
before  Operation? — This  depends  to  a  certain  degree  on  the  condition  of 
the  patient  and  the  stage  of  the  disease.  When  a  man  between  the  ages 
of  fifty  and  sixty  years  comes  to  the  physician  suffering  from  some 
increasing  disorder  of  the  bladder,  and  is  still  in  good  physical  condition, 
great  care  should  be  taken  to  make  as  complete  a  diagnosis  as  possible 
before  operation  is  advised.  Frequently  a  stone  in  the  bladder  is  the 
cause  of  the  symptoms.  Sometimes  a  neglected  stricture  of  the  urethra 
is  found  and,  in  fact,  there  are  a  number  of  diseases  other  than  an 
enlarged  prostate  any  one  of  which  might  be  the  cause  of  his  symptoms. 
We  feel  that  many  disasters  and  incomplete  operations  would  be 
avoided  if  more  care  were  taken  to  make  an  exact  diagnosis.  The  same 
rule  should  apply  to  the  older  patients  who  are  not  in  the  advanced 


588  PROSTATIC  OBSTRUCTIONS 

stages  of  the  disease.  On  the  other  hand,  where  the  patient  is  weak 
and  infirm,  and  where  the  patient  has  been  subjected  to  proper  methods 
of  treatment  to  overcome  his  urinary  stasis  without  success,  we  are 
justified  in  operating  at  once  to  relieve  the  retention  of  urine  without 
waiting  to  make  a  complete  and  often  exhausting  examination. 

Differential  Diagnosis. — If  attempting  to  determine  the  type  of 
change  presented  in  a  given  case  of  obstruction  at  the  neck  of  the  bladder, 
it  is  important  to  remember  that  the  same  degrees  of  obstruction  may  be 
caused  either  by  the  large  glandular  hyperplasia  of  the  prostate  or  the 
less  apparent  fibrous  deformities.  The  former  is  much  more  frequent 
in  men  past  sixty,  while  the  latter  is  more  often  encountered  in  men  who 
are  younger.  With  regard  to  the  clinical  symptoms  there  is  consider- 
able difference  of  opinion.  Some  observers  believe  that  the  bladder 
symptoms  are  more  distressing  wrhen  fibrous  changes  are  present,  espe- 
cially those  which  are  the  sequellse  of  inflammation,  while  on  the 
other  hand  we  do  not  see  some  cases  of  glandular  hyperplasia  until  after 
infection  has  taken  place  and  our  clinical  picture  is  obscured.  In  fact 
many  patients  of  the  latter  type  suffer  from  as  marked  dysuria  as  those 
of  the  former.  Therefore  we  cannot  depend  on  the  symptoms  alone, 
but  each  case,  when  doubt  arises,  must  be  judged  on  the  evidence 
obtained  from  a  confined  urethral,  rectal,  and  cystoscopic  exami- 
nation. 

Chronic  Prostatitis. — There  is  usually  a  previous  history  of  acute 
prostatitis.  The  clinical  symptoms  are  often  very  slight  and  are  not 
characteristic.  There  is  usually  an  uneven  enlargement  of  the  prostate 
appreciable  by  rectal  examination.  The  prostatic  secretion,  expressed 
by  massage  of  the  gland,  and  examined,  contains  pus  cells.  When  the 
disease  is  of  long  standing,  and  has  invaded  the  interglandular  struc- 
tures, more  lasting  changes  take  place  and  chronic  obstruction  may 
become  established. 

As  a  rule  the  cystoscope  is  not  of  great  value  here.  It  may,  how- 
ever, serve  to  differentiate  between  a  chronic  prostatitis  and  a  median- 
lobe  enlargement  of  the  prostate.  Where  the  median  lobe  is  enlarged, 
the  obstruction  at  the  vesical  neck  is  found  to  be  caused  by  a  smooth, 
rounded  swelling  which  overlaps  but  does  not  necessarily  encroach 
upon  the  trigone.  With  chronic  prostatitis,  the  posterior  segment  of 
the  prostatic  urethra  appears  hyperemic,  swollen,  and  infiltrated,  so 
that  when  the  instrument  is  pressed  against  it,  it  does  not  yield  as  easily 
as  does  the  median-lobe  enlargement.  The  swelling  and  infiltration  may 
cause  a  slight  bar  formation  with  a  pouch  behind  it,  and  the  trigone 
itself  may  also  be  infiltrated  and  thickened. 

Tuberculosis  of  the  Prostate. — -If  tuberculous  disease  of  the  prostate, 
without  involvement  of  the  bladder,  is  suspected,  the  passage  of  a 
cystoscope  or  other  instrument  for  examination  is  usually  contra- 
indicated.  In  the  presence  of  severe  bladder  symptoms,  it  is  justifiable 
to  use  the  cystoscope.  The  prostate  will  be  found  to  be  irregularly 
enlarged  and  its  surface  hyperemic  and  granulated.  The  hyperemia 
and  irregularity  of  the  surface  and  the  lack  of  extensive  hypertrophy 


ENLARGEMENT  OF  PROSTATE  589 

will  often  give  a  clue  to  the  true  condition  of  the  prostate.  In  the  more 
advanced  cases  ulceration  may  be  present,  and  if  so,  bleeding  takes 
place  very  easily.  Rectal  examination  in  combination  with  visual 
examination  of  the  organ  and  the  almost  invariable  presence  of  tubercle 
bacilli  will  make  the  diagnosis  easy. 

Carcinoma  of  the  Prostate. — The  question  of  the  diagnosis  of  this  con- 
dition has  been  fully  reviewed  in  a  subsequent  chapter.  It  may  be  well 
to  emphasize  the  fact  that  it  is  sometimes  very  difficult  and  sometimes 
impossible  to  make  a  definite  diagnosis  of  carcinoma  of  the  prostate. 
The  disease  usually  begins  in  the  posterior  lobe  and  extends  toward  the 
trigone  of  the  bladder  without,  as  a  rule,  involving  the  mucous  mem- 
brane covering  it.  Rectal  examination  reveals  the  prostate  with  areas 
of  dense  induration,  in  places  as  hard  as  a  stone.  If  the  glandular 
elements  have  become  involved,  the  entire  lobe  may  feel  like  a  calculus, 
but,  as  a  rule,  it  is  not  very  greatly  enlarged.  With  a  cystoscope  we 
find  that  although  there  has  been  considerable  residual  urine  still  there 
is  no  considerable  hypertrophy  or  overgrowth  of  the  prostate  extending 
into  the  bladder.  Secondly,  the  trigone  is  lifted  and  is  decidedly 
more  prominent  than  normal,  and  does  not  shift  its  position  with  the 
filling  or  emptying  of  the  bladder.  We  can  see,  at  the  same  time, 
whether  or  not  there  is  any  involvement  of  the  bladder  mucous  mem- 
brane. 

Conditions  Simulating  Prostatic  Disease. — 1.  Retention  of  Urine  Due 
to  Spinal  Disease. — Diseases  of  the  spinal  cord  affect  the  bladder  by 
causing  incomplete  muscular  control,  resulting  in  partial  or  complete 
loss  of  its  power  of  expelling  the  urine.  The  patient  passes  urine  fre- 
quently day  and  night,  but  never  empties  the  bladder  completely. 
Cystoscopic  examination  shows  no  hypertrophy  of  the  prostate  or 
median-bar  formation.  Young  states  that  when  disease  simulating 
prostatic  obstruction  comes  on  late  in  life,  and  both  rectal  and  cysto- 
scopic  examination  show  no  hypertrophy  or  median-bar  formation, 
with  a  large  residual  urine,  we  should  suspect  spinal  disease. 

In  addition  to  the  ordinary  means  of  detecting  spinal-cord  lesions,  the 
laboratory  tests  of  the  blood  and  spinal  fluid  will  help  to  establish  a 
correct  diagnosis. 

2.  Vesical  Tumors  Simulating  Prostatic  Disease. — To  differentiate 
between  a  vesical  tumor  and  prostatic  enlargement  is  not,  as  a  rule, 
difficult  inasmuch  as  the  clinical  symptoms  are  usually  quite  distinct. 
Some  neoplasms,  however,  arising  from  or  near  the  prostate  are  impos- 
sible of  differentiation.  If,  however,  we  make  an  examination  of  the 
prostate  and  find  that  the  prostatic  body  itself  is  not  enlarged,  or  only 
slightly  enlarged,  and  that  at  one  point  there  is  a  decided  outgrowth  of 
new  tissue,  a  vesical  tumor  may  be  suspected.  As  a  rule,  however,  the 
tumor  arises  independent  of  the  prostate,  and  by  careful  examination 
we  are  able  to  see  a  lack  of  continuity  between  the  prostate  and  the 
growth,  with  a  distinct  area  of  normal  vesical  mucosa  intervening.  The 
ordinary  papillomatous  and  ulcerating  types  of  carcinoma  are  not 
difficult  to  differentiate.  But  a  carcinoma  involving  the  base  of  the 


590  PROSTATIC  OBSTRUCTIONS 

bladder,  or  a  carcinoma  infiltrating  the  base  without  ulceration,  are 
extremely  difficult  to  recognize. 

3.  Vesical  Calculus  Simulating  Prostatic  Disease. — In  patients  over 
sixty-five  years  of  age  a  calculus  may  form  so  gradually  that  it  is  not 
suspected,  the  symptoms  at  no  time  being  very  severe.  The  first 
evidence  of  its  presence  may  be  due  to  the  congestion  of  the  prostate 
caused  by  a  stone  pressing  against  it.  The  first  symptoms  are 
usually  frequency  of  urination  during  the  day.  Many  such  cases 
have  been  operated  upon  and  the  prostate  removed,  leaving  the  stone 
in  the  bladder,  with  the  recurrence  of  the  symptoms  and  the  necessity 
of  another  operation.  Cystoscopic  examination  will,  of  course,  clear 
up  the  diagnosis,  and  a  suitable  operation  will  relieve  the  patient  of  his 
prostatic  and  vesical  symptoms.  Vesical  calculi  are  present  in  about 
25  per  cent,  of  all  cases  of  prostatic  hypertrophy.  The  stone  may  be 
found  in  the  postprostatic  pouch  or  it  may  occupy  a  diverticulum.  If 
a  stone  is  found  occupying  a  fixed  position  on  the  base  of  the  bladder, 
it  is  extremely  important  to  make  a  rectal  examination  in  order  to 
ascertain  whether  or  not  a  portion  of  the  stone  is  hidden  in  a  diver- 
ticulum. 

Treatment. — In  considering  the  treatment  of  obstructions  due  to  en- 
largements of  the  prostate  or  their  associated  lesions — deformities  of  the 
prostate — one  must  realize  that  we  are  dealing  with  lesions  which  are 
almost  without  exception  progressive.  The  seeming  recessions  are  not 
due  to  actual  tissue  changes  in  the  prostate,  but  are  the  result  simply  of 
a  lessened  congestion,  or  removal  of  some  irritating  substance,  causing 
edema  of  the  prostate  and  its  surrounding  structures.  As  age 
advances  the  hyperplasia  increases  and  in  this  way  differs  from  the 
ordinary  diseases  of  the  body  which  frequently  are  associated  with 
atrophy  of  the  tissue  after  a  certain  age.  Therefore  we  cannot  employ 
palliative  measures  in  the  hope  of  carrying  the  patient  over  a  certain 
period  of  advancing  enlargement,  but  must  face  the  fact  that  eventually 
the  case  will  come  to  operation  if  it  is  a  true  hypertrophy,  or  death  will 
result  when  our  operative  means  fail  to  relieve  the  retention  of  urine 
and  the  infections  of  the  urinary  tract. 

Hygienic  Considerations. — The  same  general  rules  of  hygiene  apply 
to  these  elderly  patients  as  apply  to  any  condition  of  ill  health  in  a  man 
of  mature  years.  It  is  especially  important  that  the  diet  at  all 
times  should,  be  mild;  fruit  juices  are  distinctly  beneficial.  Chilling 
of  the  body,  wetting  the  feet,  violent  exercise,  and  in  fact  anything 
which  would  tend  to  increase  congestion  of  the  pelvic  organs,  will  cause 
an  increase  of  the  distressing  symptoms.  In  the  earlier  stages  the  patient 
often  is  tempted  to  hold  his  urine  longer  than  he  should.  This  has  very 
frequently  been  followed  by  acute  retention  and  has  led  to  the  first 
introduction  of  a  catheter.  Out-of-door  life,  moderate  exercise,  a  bland 
diet,  regularity  of  the  bowels,  regularity  of  meals,  abstinence  from  alco- 
hol, regular  hours  of  sleep,  a  constant  protection  of  the  abdomen  and 
pelvis  from  sudden  chilling — these  are  the  most  important  details  in 
the  life  of  the  patient  with  an  enlarging  prostate. 


•ENLARGEMENT  OF  PROSTATE  591 

The  treatment  of  the  early  stages  of  enlargements  of  the  prostate 
resolve  themselves  almost  entirely  into  treatment  of  urinary  stasis. 
Later,  infections  of  the  bladder  and  kidney  appear  and  need  to  be  dealt 
with. 

When  the  symptoms  in  the  early  stage  are  intensified  by  the  incidence 
of  congestion  or  inflammation  of  the  prostate  they  may  be  dealt  with  by 
non-operative  methods.  This  consists  of  relieving  the  congestion  of  the 
pelvic  organs  as  much  as  possible,  by  administering  enemata  to  empty 
the  bowel,  by  repeated  sitz  baths,  by  hot  rectal  irrigations,  by  pros- 
tatic  massage,  and  by  the  exhibition  of  such  drugs  as  urotropin, 
benzoate  of  soda,  santal  oil  and  the  various  balsams. 

Treatment  of  Acute  Retention  of  Urine. — If  possible,  the  introduction 
of  a  catheter  by  the  urethra  under  these  conditions  is  to  be  resorted  to 
only  after  all  other  means  of  relieving  the  patient  have  failed.  Water 
and  fluids  by  mouth  should  be  restricted,  rest  in  bed  should  be  insisted 
upon.  The  patient  should  try  to  empty  his  bladder  while  sitting  in 
a  tub  of  hot  water,  and  should  be  given  various  narcotics  to  diminish 
the  reflex  spasm  of  his  internal  sphincter  muscle.  If  all  these  measures 
fail,  then  a  relatively  stiff  silk-webbing  catheter  of  the  bougie  or  Mercier 
coude  type,  preferably  18  to  22  of  the  French  scale  in  size,  should  be 
slowly  and  carefully  introduced.  It  is  our  belief  that  less  harm  is  done 
with  a  silk  catheter  than  with  a  soft-rubber  catheter,  which  easily  bends 
upon  itself  when  it  reaches  the  posterior  urethra  and  sometimes  causes 
very  considerable  injury.  With  acute  retention,  if  a  catheter  has 
entered  the  bladder,  the  urine  is  allowed  to  escape  slowly  and,  if  the 
bladder  does  not  contain  more  than  20  ounces  or  thereabouts,  it  may 
be  entirely  emptied.  If  there  is  an  enormous  distention  of  the  bladder, 
not  more  than  20  ounces  should  be  withdrawn  at  one  time  and  a  catheter 
should  be  left  in  place,  properly  stoppered,  and  the  urine  allowed  to 
flow  out  from  the  bladder  at  intervals  of  from  fifteen  to  twenty  minutes 
until  it  is  emptied.  Then  a  non-irritating  solution  should  be  injected 
into  the  bladder  and  left  there.  The  patient  should  be  placed  on  a 
restricted  diet  of  milk,  should  be  kept  perfectly  quiet,  should  have  his 
pelvis  carefully  protected  and  heat  applied,  and  it  will  usually  be  found 
that  it  is  unnecessary  to  pass  the  catheter  more  than  once  in  this 
manner.  If  repeated  catheterism  is  necessary,  the  same  precautions 
must  be  observed  each  time. 

Treatment  of  Cystitis  with  Urinary  Stasis. — If  infection  of  the  bladder 
has  taken  place,  the  bladder  should  be  catheterized  each  day,  carefully 
washed  out  and  injected  with  sterilized  oil  or  some  silver  salt.  Two 
ounces  of  0.5  per  cent,  solution  of  silver  nitrate  is  probably  the  best 
solution  to  use  in  these  cases.  It  should  be  allowed  to  remain  in 
the  bladder  for  from  five  to  ten  minutes  and  then  withdrawn. 
This  treatment  should  be  continued  until  the  cystitis  is  over- 
come. 

It  is  not  our  province  here  to  discuss  the  treatment  of  inflammatory 
conditions  of  the  prostate,  and  the  reader  is  referred  to  the  chapter 
dealing  with  this  subject. 


592  PROSTATIC  OBSTRUCTIONS 

Catheter  Treatment  of  Cases  of  Urinary  Stasis  Due  to  Prostatic  Enlarge- 
ment.— Increasing  experience  has  more  than  ever  demonstrated  that  the 
safest  method  of  treating  urinary  retention  due  to  obstructive  enlarge- 
ment of  the  prostate  is  by  suprapubic  drainage.  This  conclusion,  of 
course,  applies  only  to  the  cases  that  have  reached  the  stage  of  chronic 
retention  of  urine.  The  fact  that  a  man  has  an  hypertrophied  prostate 
is  no  argument  for  its  removal  unless  it  is  causing  active  symptoms. 
The  dictum  does  not  apply  to  the  beginning  stages  of  hypertrophied 
prostate  where  we  are  called  upon  to  treat  active  congestions .  from 
irritations  of  an  enlarging  prostate.  But  when  enlargement  of  the 
prostate  is  causing  sufficiently  grave  symptoms  to  demand  some 
artificial  means  of  emptying  the  bladder,  the  better  procedure  is  through 
an  opening  above  the  pubis. 

The  statistics  compiled  by  various  urologists  have  demonstrated 
again  and  again  that  sooner  or  later  within  a  relatively  short  period  of 
tune  death  from  sepsis  results  from  the  initiation  of  catheter  treatment. 

In  a  work  of  this  kind  it  is  not  our  purpose  to  repeat  the  instructions 
for  the  choice  of  catheter,  the  methods  of  its  sterilization  and  its  means 
of  introduction  which  have  been  so  carefully  worked  out  and  written 
down  by  many  previous  writers.  The  same  catheters  and  instruments 
are  indicated  in  those  cases  where  catheter  treatment  is  insisted  upon 
as  are  used  for  the  purpose  of  diagnosis  in  cases  of  advanced  prostatic 
disease. 

We  believe  that  there  are  very  few  cases,  indeed,  where  one  is  justi- 
fied in  advising  catheter  life.  In  those  exceptional  cases  where  the 
condition  of  the  patient  will  not  permit  of  operation,  the  physician 
should  himself  select  a  catheter  and  instruct  the  patient  in  its  use.  He 
should  advise  the  patient  to  empty  his  bladder  by  means  of  a  catheter 
regularly  night  and  morning  and  should  tell  him  that  more  frequent 
catheterism  is  undertaken  at  the  patient's  own  risk.  It  is  manifestly 
more  dangerous  for  any  patient  to  have  the  catheter  passed  through 
his  urethra  four  or  five  times  a  day  than  it  is  to  have  a  suprapubic 
cystostomy  performed  under  local  anesthesia. 

Intra-urethral  Methods  of  Treatment. — As  a  palliative  measure  in 
enlargements  of  the  prostate  due  to  congestion  and  inflammatory  pro- 
cesses, the  catheter  is  frequently  employed.  Its  uses  in  the  early  stages 
of  a  true  hypertrophy  of  the  prostate  have  already  been  referred  to. 

There  are,  however,  a  set  of  cases  in  which  intra-urethral  methods  of 
treatment  should  be  the  methods  of  choice.  These  methods  range 
from  minor  surgical  procedures  carried  out  through  an  endoscope, 
including  the  application  of  the  high-frequency  spark,  to  the  more 
radical  punch  operation  of  Young  and  the  more  dangerous  galvano- 
cautery  operation  of  Bottini  and  the  modification  of  this  method 
advised  by  Chetwood.  The  cases  in  which  these  methods  of  treatment 
are  called  for  are  those  which  fall  into  the  class  already  described  under 
Urinary  Obstruction  without  Hypertrophy  of  the  Prostate,  i.  e.,  sub- 
mucous  fibrosis,  deformed  orifice  due  to  inflammation,  and  hyperplasia 
of  the  suburethral  and  subtrigonal  group  of  glands. 


ENLARGEMENT  OF  PROSTATE  593 

The  centra-indications  to  the  more  radical  operation  of  pros- 
tatectomy are  practically  the  same  as  those  governing  any  major 
surgical  operation  in  a  patient  of  the  same  age. 

We  divide  then  our  recommendations  for  treatment  into  four  classes : 

1 .  Palliative  treatment  in  the  prostatic  enlargements  due  to  congestive 
or  inflammatory  causes,  also  in  the  cases  in  which  surgical  operation  is 
contra-ind  icated . 

2.  Intra-urethral  surgical  treatment  in  the  cases  of  urinary  obstruction 
without  hypertrophy  of  the  prostate. 

3.  Suprapubic  cystostomy,  as  a  preliminary  step  to  prostatectomy, 
and  as  a  permanent  means  of  relieving  retention  of  urine  in  cases  in 
which  prostatectomy  is  contra-indicated. 

4.  Prostatectomy,  either  perineal  or  suprapubic  transvesical,  in  all 
cases  of  true  hypertrophy  of  the  prostate. 

Palliative  Treatment. — Why  is  this  not  justifiable  in  the  cases  of 
true  prostatic  hypertrophy  ?  It  may  be  tried  as  a  temporary  expedient, 
and  then  only  in  the  early  stages  of  the  disease;  but  in  the  light  of  our 
present  experience  always  under  protest  rather  than  as  a  measure 
possessing  the  full  recommendation  of  the  surgeon. 

Doubtless  in  many  cases  operation  on  the  first  appearance  of  serious 
obstructive  symptoms  will  be  impracticable,  either  through  the  disin- 
clination of  the  patient  to  submit  to  such  an  operation  as  prostatectomy, 
or  his  inability  to  give  up  from  his  occupation  the  time  required  for  its 
performance  and  recovery  thereupon.  The  catheter  may  be  employed, 
provided  its  use  is  found  to  be  unattended  with  any  special  trouble  or 
discomfort. 

Intermittent  Catheterism. — As  a  temporary  expedient  to  relieve  an 
obstruction  which  may  be  expected  to  shortly  disappear,  intermittent 
catheterism  is  simple  and  efficient.  It  has  its  dangers,  which  consist, 
first,  of  possibilities  of  septic  infection,  which,  while  they  may  be  reduced 
to  a  minimum  by  extreme  care,-  are  nevertheless  always  present,  and  in 
the  peculiar  conditions  which  surround  patients  suffering  from  urethral 
obstruction  the  necessary  precautions  are  usually  sooner  or  later  im- 
perfectly observed,  and  the  introduction  of  sepsis  takes  place.  It  is  a 
matter  of  occasional  observation,  however,  that  certain  individuals 
exhibit  a  marked  immunity  to  the  results  of  such  infection,  indeed  in 
some  cases  the  use  of  an  unclean  catheter  is  persisted  in  for  years  with 
the  production  of  only  a  very  moderate  amount  of  septic  infection  in 
the  bladder.  These  cases,  however,  are  so  rare  as  to  make  more 
emphatic  the  statement  that  the  continued  use  of  a  catheter  is  sure  to 
result  in  a  train  of  septic  consequences  of  the  most  serious  character. 
The  majority  of  patients  who  elect  to  depend  upon  the  continued  use 
of  the  catheter  for  urinary  relief  enter  upon  a  course  which  in  itself 
progresses  steadily  to  fatal  termination  within  a  brief  period. 

The  second  danger  attending  the  use  of  a  catheter  is  the  immediate 
constitutional  reaction  which  in  occasional  instances  has  been  observed 
to  follow  its  use,  a  reaction  so  profound  in  some  cases  as  to  terminate 
in  death  within  a  very  few  hours. 

M  tr     i — 38 


594  PROSTATIC  OBSTRUCTIONS 

The  third  danger  is  referable  to  the  local  irritation,  or  traumatism, 
with  which  its  introduction  is  attended.  As  the  result  of  this 
there  is  pain  and  constitutional  disturbance,  though  of  a  lesser 
degree  than  has  already  been  mentioned,  which  follows  each 
attempt  at  the  introduction  of  the  catheter.  In  those  conditions 
of  obstruction  due  to  prostatic  enlargement  in  which  the  question 
of  catheter  relief  comes  up  for  consideration,  the  character  of 
the  obstruction  is  such  as  frequently  to  insure  and  accentuate  the 
pains  and  difficulties  just  indicated.  These  difficulties  may  often 
be  very  greatly  lessened  or  modified  by  the  choice  of  the  best  model 
of  an  instrument  or  by  skill  in  its  introduction,  but  in  many  cases 
even  with  the  highest  degree  of  skill  and  the  best  of  instruments 
the  local  irritation  incident  to  persistent  attempts  at  the  use  of  a 
catheter  becomes  so  great  as  to  be  a  serious  element  in  the  dangers 
of  the  case. 

The  Catheter  a  demeure. — As  a  substitute  for  intermittent  catheterism 
the  permanent  tying  in  place  in  the  bladder  of  a  catheter  is  to  be  con- 
sidered. Its  value  has  received  the  commendation  of  men  of  the  high- 
est authority.  Practically,  however,  it  is  found  that  marked  differences 
exist  in  individuals  as  to  their  ability  to  tolerate  the  presence  in  the 
urethra  of  the  instrument.  When  it  can  be  tolerated,  its  use  is  free 
from  the  special  difficulties  and  miseries  incident  to  the  continued  fre- 
quent introduction  of  an  instrument,  especially  in  those  cases  in  which 
the  introduction  of  an  instrument  is  difficult.  In  the  best  of  cases, 
however,  there  is  a  certain  amount  of  irritation  of  the  urethral  mucosa 
which  attends  its  presence  in  the  urethra;  a  moderate  urethritis  is 
produced.  The  irritation  of  the  deep  urethra  is  of  special  consequence 
in  this  connection,  if,  as  seems  to  be  well  substantiated,  there  is  any 
special  nervous  relation  between  this  portion  of  the  urethra  and  the 
secretory  apparatus  of  the  kidneys.  One  of  the  alarming  results  which 
attend  the  second  group  of  dangers  connected  with  the  use  of  the 
catheter,  already  alluded  to,  is  anuria  directly  dependent  upon  the 
irritation  of  the  deep  urethra,  caused  by  the  use  of  a  catheter.  This 
reflex  effect  upon  the  renal  secretory  apparatus  must  be  Kept  in  mind  in 
determining  the  propriety  of  introducing  or  maintaining  a  permanent 
urethral  catheter.  This  must  be  of  special  importance  in  those  cases  in 
which  reflex  renal  disturbances  dependent  upon  urethral  and  bladder 
conditions  have  already  been  demonstrated.  It  is  in  this  last  group  of 
cases  more  particularly  that,  as  a  substitute  for  a  permanent  urethral 
catheter,  the  opening  of  the  bladder  above  the  pubis  and  the  securing 
within  the  opening  of  a  suitable  drain  to  relieve  the  urethra  entirely 
suggests  itself. 

Suprapubic  Cystostomy. — Suprapubic  cystostomy  is  a  surgical  pro- 
cedure that  has  its  own  perils  and  requires  the  most  careful  attention 
to  details  of  technic  to  reduce  its  dangers  to  a  minimum.  It  commends 
itself  especially  in  those  cases  in  which  a  temporary  relief  to  urinary 
prostatic  obstruction  is  desired  while  the  best  general  and  local  con- 
ditions are  being  secured  for  the  later  radical  removal  of  the  obstruc- 


ENLARGEMENT  OF  PROSTATE  595 

tion  itself.  It  is  free  from  any  of  the  reflex  effects  which  attend  the 
introduction  or  retaining  of  a  catheter  in  the  urethra.  It  has  still 
further  the  advantage  not  only  of  easy  and  adequate  urinary  drainage, 
but  also  of  placing  at  rest  the  urethral  tract  and  of  being  the  most 
powerful  agent  in  overcoming  any  reflex  influence  which  the  irritation 
of  that  tract  may  previously  have  been  producing. 

It  is  impossible  to  emphasize  too  strongly  the  great  dangers  of  cathe- 
ter life,  and  the  lessening  of  the  chances  of  complete  recovery  which 
delay  and  the  inevitable  infections  of  the  bladder  and  kidney  entail. 
Moullin8  in  his  work  on  the  prostate  states,  "  I  have  more  than  once 
known  suppression  of  urine  to  be  caused  by  the  introduction  of  a  cathe- 
ter into  the  urethra."  And  later,  "Tying  in  a  catheter  must  be 
regarded  as  a  measure  that  should  only  be  adopted  when  nothing  else 
can  be  done."  Likewise  Wallace15  in  his  book  says :  "'  The  fact  must  be 
faced,  that  a  patient  practising  self-ca the teriza tion  is  almost  sure  to 
fall  a  victim  to  septic  infection  of  the  urinary  tract." 

Figures  sometimes  emphasize  a  fact  better  than  argument.  From  a 
series  of  thirty  cases  not  subjected  to  operation  and  observed  by  Squier11 
the  following  conclusions  were  drawn : 

Fifty  per  cent,  of  unoperated  cases  will  die  within  five  years  from  the 
onset  of  obstructive  symptoms,  where  catheter  life  is  not  employed. 
The  beginning  of  catheter  life  shortens  this  expectation  of  life  almost 
50  per  cent,  (two  years  and  ten  months)  and  increases  the  mortality 
66.67  per  cent,  within  the  shortened  period.  Fourteen  of  the  seventeen 
patients  who  took  up  catheter  life  died  with  an  average  duration  of  life 
of  two  years  and  ten  months. 

On  the  other  hand,  the  immediate  mortality  following  prostatectomy 
when  properly  performed  is  about  5  per  cent,  and  the  expectation  of 
complete  relief  is  over  80  per  cent. 

Surgical  Indications. — The  satisfactory  establishment  of  surgical 
efforts  for  the  radical  removal  of  urinary  obstruction,  caused  by 
enlargements  of  the  prostate  gland,  must  be  accepted  as  now  thor- 
oughly accomplished. 

It  is  of  interest  to  note,  in  surveying  the  literature  of  the  subject, 
that  among  the  many  different  methods  of  attacking  the  prostate  that 
have  been  proposed  by  different  surgeons,  practically  equally  good 
results  are  reported  to  have  been  secured  by  the  most  diverse  methods 
by  men  who  have  become  specially  skilled  in  their  application.  It 
cannot  be,  however,  that  the  choice  of  a  method  is  a  matter  of  indiffer- 
ence, a  question  of  chance  or  prejudice.  In  view  of  the  frequency  of 
the  malady,  the  general  recognition  of  the  possibilities  of  operative 
relief  will  prompt  the  surgeon  to  supply  it.  So  the  question  is  no 
longer  what  is  possible  in  the  hands  of  the  expert,  but  what,  in  the 
light  of  our  present  knowledge  of  the  anatomical  relations  and  the 
pathological  changes  of  the  prostate  gland,  will  in  the  hands  of  the 
average  surgeon  most  certainly  and  safely,  wholly  and  permanently, 
relieve  the  obstructive  dysuria  that  the  prostatic  disease  had  produced. 

The  question  of  mortality  naturally  takes  precedence  in  the  con- 


596  PROSTATIC  OBSTRUCTIONS 

sideration  of  any  operative  proposition.  There  must  of  necessity  be 
some  mortality  in  any  and  every  kind  of  surgical  intervention  in  pros- 
tatic  patients.  Sepsis,  renal  insufficiency,  and  the  multiple  degenera- 
tions incident  to  old  age  are  complications  in  varying  degrees  of  com- 
bination, that  have  to  be  reckoned  with  in  many  instances,  and  which 
must  determine  a  fatal  exit  inevitably  in  a  certain  proportion.  The 
proper  selection  of  cases  and  the  due  preparation  of  them  for  the 
hazards  of  operation  will  always  engage  the  earnest  attention  of 
the  surgeon,  and  by  these  means  the  mortality  will  be  kept  at  a 
minimum.  With  the  demonstration  of  the  comparative  safety  and 
certain  benefits  of  operation  will  come  a  resort  to  it  much  earlier  in 
the  course  of  the  disease  than  has  hitherto  been  the  case,  and  with  this 
will  come  a  marked  diminution  in  its  hazards  and  a  corresponding 
lowering  of  its  death-rate. 

The  greatest  advance  made  in  prostatic  surgery  in  the  last  decade 
has  been  the  appreciation  of  the  value  of  treatment  preliminary  to 
removal  of  the  prostate.  This  has  not  only  lowered  the  mortality  rate 
in  the  total  number  of  cases  operated  upon,  but  in  addition  has  made 
it  possible  to  offer  operative  relief  to  a  class  of  patients  who  previously 
were  denied  operation. 

In  a  word  the  chief  object  of  preliminary  treatment  is  the  relief  of 
the  urinary  stasis  through  drainage  of  bladder. 

The  primary  effect  of  the  drainage  is  decompression  of  the  kidney; 
continuance  of  the  drainage  means  a  readjustment  of  the  renal  function. 

Before  discussing  the  relative  value  of  the  various  methods  of  accom- 
plishing this  decompression  it  will  be  well  to  review  the  evidence  at 
hand  showing  the  cycle  of  renal  functional  adjustment  in  urinary 
obstruction. 

Clinical  Evidence. — The  clinician  will  observe,  in  cases  of  prostatic 
disease  in  which  there  is  considerable  retention  of  urine,  that  there 
will  be  evidences  of  intestinal  stasis,  loss  of  appetite,  loss  of  sleep, 
changes  in  temperament,  mental  degeneration,  loss  of  weight  and  a 
general  deterioration  of  the  entire  organism.  Aside  from  this,  further 
examination  may  show  various  phases  of  uremic  poisoning;  in  many 
cases  a  very  marked  increase  in  the  secretion  of  urine  with  low  specific 
gravity.  Frequently  the  amount  of  urine  will  reach  150  ounces  in 
twenty-four  hours  and  its  specific  gravity  be  as  low  as  1.002.  In 
one  case  the  twenty-four-hour  record  was  over  300  ounces.  This,  of 
course  is  an  indication  of  functional  derangement  of  the  kidney.  The 
rapid  disappearance  of  all  these  clinical  evidences  of  disturbed  renal 
function,  which  frequently  follows  drainage  of  the  bladder,  shows  the 
direct  relation  of  cause  and  effect. 

We  have  both  acute  and  chronic,  partial  and  complete  forms  of 
obstruction. 

In  the  cases  of  chronic  partial  obstruction  it  has  been  noted  in  general 
that  the  amount  of  urine  secreted  is  increased,  providing  the  bladder 
is  strong  enough  to  regularly  overcome  the  partial  obstruction,  and 
partially  empty  the  bladder  so  that  at  no  time  the  back  pressure  from 


ENLARGEMENT  OF  PROSTATE  597 

the  viscus  is  continually  great.  Where  the  musculature  of  the  bladder 
is  not  so  strong,  and  there  is  a  chronic  retention  of  a  considerable 
amount  of  urine  with  very  little  overflow,  the  quantity  secreted  will 
often  average  as  high  as  120  to  150  ounces  in  twenty-four  hours  with 
a  low  specific  gravity. 

Where  we  have  a  contracted  bladder  with  greatly  thickened  walls,  in 
which  there  is  only  a  small  amount  of  urine  retained,  and  its 
quantity  almost  entirely  fills  the  contracted  bladder,  the  urine  is 
passed  very  frequently  and  in  small  amounts.  Such  a  bladder  may 
contain  only  two  or  three  ounces  and  is  almost  continuously  full.  Under 
such  conditions  the  kidney  diminishes  its  secretion.  The  total  amount 
secreted  in  twenty-four  hours  may  be  very  little,  finally  resulting  in 
complete  anuria. 

The  other  cases  are  those  of  acute  retention  of  urine,  in  which  the 
kidneys  act  freely  until  the  bladder  is  filled  to  its  capacity,  at  which 
time  they  stop  acting  entirely. 

Aside  from  the  clinical  evidence  of  renal  infection  and  renal  insuffici- 
ency already  presented,  the  most  striking  evidence  of  renal  injury  due 
to  prostatic  obstruction  is  presented  in  those  patients  dying  from  the 
disease.  Autopsy  shows  a  variety  of  conditions  existing  in  the  kidney, 
the  most  common  lesion  being  a  distended  ureter  beginning  immedi- 
ately above  the  bladder,  resulting  in  various  degrees  of  hydronephrosis 
and  destruction  of  the  kidney  parenchyma.  This  in  turn  is  influenced 
by  the  degree  and  duration  of  the  obstruction  and  in  many  of  the 
advanced  cases  is  accompanied  by  infection,  the  formation  of  renal 
calculi,  and,  in  some,  by  almost  total  destruction  of  the  kidney 
parenchyma. 

Operative  Proof. — From  a  careful  study  of  a  series  of  cases  in  which  a 
preliminary  cystostomy  was  done,  certain  phenomena  were  repeatedly 
observed  wrhich  seemed  to  justify  us  in  dividing  the  results  of  advanced 
prostatic  obstruction  into  three  forms.  It  has  further  emphasized  in 
our  minds  the  peculiar  balance  existing  between  the  heart,  kidney, 
secretion  of  urine,  and  the  nervous  control  of  these  in  the  patient  who 
has  gradually  become  used  to  overdistention  of  the  bladder. 

We  have  learned  not  to  rely  upon  any  one  clinical  sign  or  symptom  in 
judging  the  fitness  of  the  patient  for  operation.  We  have  learned  that 
the  balance  between  the  various  elements  of  the  system  is  so  adjusted 
that  a  disturbance  of  one  of  them  will  bring  to  light  weakness  in  some 
of  the  others  which  has  not  been  suspected,  for  example,  as  may  appear 
in  the  phthalein  excretion  by  the  kidney.  This  may  be  very  deceptive. 
The  patient  may  show  50  to  60  per  cent,  of  excretion  of  phthalein  in  two 
hours  before  anything  has  been  done  to  relieve  the  retention  of  urine. 
Drain  the  residual  urine  from  the  bladder  and  all  of  the  other  elements 
of  the  system  are  thrown  into  confusion.  The  back  pressure  is  relieved ; 
decompression  of  the  kidney  follows;  swelling  and  congestion  of  the 
organ  take  place;  and  its  functional  capacity  immediately  drops  to  a 
very  low  point.  The  outward  signs  of  this  derangement  are  very 
evident.  This  is  the  second  phase.  It  is  our  belief  that  in  the  case  of 


598 


PROSTATIC  OBSTRUCTIONS 


many  of  the  patients  who  have  died  following  operation,  death  has 
resulted  from  a  lack  of  appreciation  of  this  second  phase  of  renal  dis- 
turbance. Many  deaths  have  been  reported  on  the  third  to  the  fifth 
day  following  a  one-step  prostatectomy,  when  the  patient  was  seem- 
ingly doing  well;  but  when  we  take  into  account  the  phenomena 
of  the  second  phase  in  addition  to  the  shock  of  the  major  operation 
with  its  loss  of  blood  and  the  depressing  effect  of  the  general  anes- 


URINARY 
OUTPUT 


BLOOD 
UREA 


SPECIFIC 
GRAVITY 


\ 


Ai* 


Utf 


1.020 


DAYS   1  2  3  4 

1ST  PHASE 


10       11       12 

3RD  PHASE 


2ND  PHASE 

FIG.  273. — Chart  showing  changes  taking  place  in  the  urine  following  operation. 

thetic,  it  can  be  easily  appreciated  why  these  deaths  take  place,  and 
many  will  agree  that  the  overtaxed  heart  and  the  system  overloaded 
with  toxins  which  the  kidneys  should,  but  cannot,  separate  from  the 
blood  are  the  cause  of  the  death.  Extended  observations  have 
shown  that  nearly  every  prostatic  will  present  these  three  phases, 
and  this  fact  has  influenced  us  very  greatly  in  favor  of  the  two-stage 
operation  in  every  case  of  benign  hypertrophy. 


ENLARGEMENT  OF  PROSTATE  599 

The  Three  Phases. — The  results  of  our  observations  are  graphically 
shown  on  the  accompanying  chart  (Fig.  273)  which  shows  the  average 
condition  which  prevails  in  many  advanced  cases  of  obstructive 
hypertrophy  of  the  prostate. 

The  First  Phase. — For  the  first  day,  the  day  on  which  the  suprapubic 
cystostomy  is  done,  the  blood-pressure  frequently  registers  from  200  to 
220  mm.  of  mercury;  the  urinary  output  for  twenty-four  hours  will 
average  from  70  to  120  ounces;  the  phenol-sulphone-phthalein  test  will 
frequently  average  above  50  per  cent,  in  two  hours  and  the  urine 
will  show  only  a  trace  of  albumin.  If  these  conditions  are  considered  by 
themselves,  they  will  give  us  a  false  impression  of  the  actual  condition 
of  the  patient.  For  example,  if  the  patient's  blood-pressure  registered 
200  mm.  and  he  was  passing  90  ounces  of  urine  in  twenty-four  hours 
with  low  specific  gravity  and  with  only  a  trace  of  albumin,  we  would  be 
rather  suspicious  of  the  functional  capacity  of  the  kidneys.  But  when  we 
make  a  phenolsulphonephthalein  test,  and  find  that  the  output  in  two 
hours  is  60  per  cent,  or  more,  it  might  lead  us  to  believe  that  the  actual 
functional  capacity  of  the  kidneys  is  greater  than  the  specific  gravity 
would  indicate. 

The  Second  Phase. — A  second  glance  at  the  chart  will  show  a  very 
different  condition  existing  on  the  third  or  fourth  day  after  the  bladder 
has  been  opened  and  drained.  Here  we  see  a  lowered  blood -pressure, 
probably  between  170  and  180.  The  urinary  output  has  suddenly 
dropped  15  to  20  ounces;  the  amount  of  albumin  in  the  urine  has 
increased  enormously.  On  the  third  or  fourth  day  the  phenolsulphone- 
phthalein test  shows  the  functional  capacity  of  the  kidney  at  this  most 
critical  time  to  be  only  15  per  cent.  This,  then,  is  the  change  that  has 
taken  place  simply  following  a  drainage  of  the  bladder  without  any  loss 
of  blood  or  other  surgical  shock  due  to  anesthesia  or  prolongedmanipula- 
tion.  If  to  the  shock  of  a  prostatectomy  with  its  general  anesthesia  a 
very  considerable  loss  of  blood  and  the  shock  consequent  to  pain  had 
been  added,  one  does  not  wonder  that  so  many  patients  have  died 
on  the  third,  fourth  and  fifth  day  from  no  apparent  cause. 

The  Third  Phase.- — Passing  to  the  third  phase  of  the  condition 
following  drainage  of  the  bladder,  we  find  in  the  average  case  that 
on  the  seventh  to  tenth  day  the  blood-pressure  has  decreased  to 
160  to  170  mm.,  the  urinary  output  has  increased  to  40  to  50  ounces 
in  twenty-four  hours,  the  phthalein  test  shows  a  reaction  of  the 
kidney  from  a  15  per  cent,  output  to  one  of  50  per  cent.,  and  the 
amount  of  albumin  has  decreased  very  markedly,  it  being  still  a  little 
more  than  before  the  cystostomy  and  very  much  less  than  was  found 
on  the  third  or  fourth  day. 

If  the  prostatectomy  is  performed  now,  the  effect  upon  all  these 
phenomena  is  quite  different  from  that  after  a  preliminary  cystostomy. 
In  the  latter  case  the  blood-pressure  falls  still  lower,  the  urinary  output 
decreases  very  little;  the  functional  capacity  of  the  kidney  does  not 
fall  more  than  ten  points;  it  is  difficult  to  ascertain  the  amount  of 
albumin  present  in  the  urine  on  account  of  the  presence  of  the  wound  in 


600  PROSTATIC  OBSTRUCTIONS 

the  bladder,  but  at  no  time  is  it  as  great  as  was  found  on  the  third  or 
fourth  day  after  the  cystostomy  was  performed. 

By  following  this  method  we  entirely  avoid  the  second  phase  after  the 
prostatectomy. 

Hugh  Cabot2  in  studying  the  mechanism  of  the  protection  afforded 
by  the  drainage  of  prostatics  as  a  preliminary  to  operation  has  observed 
certain  phenomena  which  lead  him  to  conclude  that  "  the  relief  appears 
to  be  the  result  of  two  factors:  (1)  Relief  of  the  so-called  "  back  pres- 
sure" with  the  equalization  of  the  kidney  circulation  thus  resulting,  and 
(2)  lessening  of  infection  which  though  long  believed  to  be  chiefly  a 
cystitis,  is  now  generally  regarded  as  in  fact  a  pyelonephritis."  He  states 
further:  "No  discussion  is  necessary  to  establish  the  now  generally 
accepted  view  that  the  custom  of  preliminary  drainage  before  operations 
for  prostatic  obstruction  has  been  an  important  factor  in  reducing  the 
mortality.  Much  obscurity,  however,  surrounds  the  reasons  for  the 
benefit  thus  produced  and  it  is  with  this  subject  that  we  are  here  con- 
cerned. The  importance  of  preliminary  drainage  is  by  no  means  equal 
in  the  various  classes  of  cases  presenting  themselves  for  operation.  It 
will  probably  be  generally  admitted  that  preliminary  treatment,  of 
which  drainage  is  the  most  important  constituent,  is  most  essential  in  the 
class  of  patients  who  come  to  us  with  largely  overdistended  bladders, 
sometimes  stretched  to  the  point  of  overflow  but  in  whom  infection  has 
not  yet  occurred.  We  all  remember  the  dreadful  mortality  which 
accompanied  the  attempt  to  empty  the  bladder  and  remove  the 
obstruction  immediately  upon  coming  under  observation.  It  is  notori- 
ous that  these  cases  did  badly  from  the  start  and  died  generally  with  the 
symptom-complex  which  we  somewhat  loosely  call  uremia.  Perhaps 
the  next  most  lethal  proceeding  was  to  operate  at  once  upon  those  cases 
with  a  moderate  residual  of  from  6  to  12  ounces  and  a  still  uninfected 
urine,  while  immediate  operation  was  least  hazardous  in  those  cases 
with  a  moderate  residual  thoroughly  infected  and  best  typified  by  the 
patients  who  had  for  some  time  been  leading  the  so-called  catheter  life. 
The  extremes  are  represented  by  the  overdistended  uninfected  bladder 
and  the  thoroughly  infected  but  regularly  emptied  bladder  enjoying  a 
catheter  life." 

Treatment  Preliminary  to  Prostatectomy. — It  is  quite  evident  then 
that  a  certain  amount  of  preliminary  treatment  is  indicated  in  every 
case  before  the  final  prostatectomy  is  attempted.  The  requirements  in 
the  given  case  must  be  judged  by  the  individual  surgeon.  In  the 
majority  of  cases  one  of  three  methods  should  be  adopted.  (1)  The 
repeated  use  of  a  catheter  to  empty  the  bladder  at  regular  intervals,  or 
(2)  The  use  of  a  catheter  a  demeure,  or  (3)  The  establishment  of 
suprapubic  drainage.  The  relative  values  of  these  methods  and  their 
indications  have  already  been  discussed  under  the  heading  of  Palliative 
Treatment.  While  in  most  cases  the  surgeon  may  employ  any  of  these 
methods  with  safety  to  the  patient,  still  there  are  cases  in  which 
definite  precautions  are  necessary.  Although  their  variety  is  great,  there 
are  certain  distinct  types  which  represent  those  most  commonly  seen. 


ENLARGEMENT  OF  PROSTATE  601 

1.  Patients   who  present   themselves   with   enormously  distended 
bladders,  as  yet  uninfected,  passing  from  70  to  150  ounces  of  urine  in 
twenty-four  hours,  with  a  low  specific  gravity  and  a  trace  of  albumin, 
but  with  a  relatively  large  percentage  of  blood  urea.     These  cases  call 
for  a  very  gradual  reduction  in  the  amount  of  residual  urine  which  can 
best  be  accomplished  by  the  use  of  a  catheter  a  demeure  with  gradual 
withdrawal  of  the  urine,  not  emptying  the  bladder  completely  for 
two  or  three  days ;  or,  in  the  hands  of  the  expert,  the  introduction  of  a 
button  drainage  tube  through  a  cystostomy  opening  and  gradually 
withdrawing  the  urine  from  the  bladder  in  this  way.     If  it  is  not  pos- 
sible to  introduce  a  catheter,  the  patient  should  be  kept  as  quiet  as 
possible  spending  most  of  his  time  in  bed,  the  bowels  moved  properly  by 
salines  and  the  amount  of  liquid  given  reduced  to  a  minimum.     At  a 
favorable  moment  the  suprapubic  cystostomy  should  be  done  under 
local  anesthesia  and  bladder  drainage  established. 

2.  Patients  with  very  frequent  urination  or  painful  dribbling  of  urine 
due  to  partial  retention  complicated  by  a  foul  cystitis  with  or  without 
the  presence  of  a  calculus.     Where  such  a  cystitis  is  present  there  is 
usually  no  centra-indication  to  the  use  of  a  catheter,  but  the  greatest 
amount  of  relief  will  be  afforded  by  a  preliminary  suprapubic  cystostomy 
which  provides  for  bladder  drainage  and  then,  depending  upon  the 
special  training  and  aptitude  of  the  operator,  he  will  do  a  perineal  or 
suprapubic  prostatectomy.     In  all  cases  where  suprapubic  cystostomy 
has  already  been  done,  transvesical  enucleation  of  the  prostate  can  be 
accomplished  more  quickly  and  with  less  shock  than  is  possible  if  a 
perineal  operation  is  attempted. 

3.  Patients  presenting  themselves  with  complete  retention  of  the 
urine,  hemorrhage  into  the  bladder,  bladder  distended,  patient  in 
shock.     Unquestionably  the  safest  procedure  in  such  a  case  is  an 
immediate   performance   of   a    suprapubic    cystostomy    under    local 
anesthesia  and  simple  drainage  of  the  bladder. 

4.  Patients  who  have  suffered  for  a  long  time  from  urinary  stasis  due 
to  prostatic  obstruction,  who  come  to  the  surgeon  as  a  last  resort  who 
are  already  suffering  from  uremic  symptoms  and  suppression  of  urine. 
Some  of  these  are  beyond  help,  while  others  may  be  brought  safely 
to  operation  and  recovery.     It  is  in  this  type  of  cases  that  we  must 
expect  some  mortality.     If  we  refused  to  operate  upon  them  our  5 
per  cent,  mortality  record  would  be  reduced  to  1  or  2  per  cent.;  but 
even  in  this  type  many  brilliant  results  are  secured.     Here  preliminary 
treatment  is  absolutely  essential  and  should  be  continued  for  two 
or  three  months  before  it  is  safe  to  enucleate  the  prostate.     It  is  in  these 
cases  especially  that  the  work  of  the  surgeon  should  be  supplemented 
by  that  of  a  physician  to  regulate  the  diet,  to  sustain  the  heart  muscle 
and  promote  the  wrell-being  of  the  patient. 

How  shall  the  surgeon  be  guided  in  selecting  the  time  to  perform  the 
prostatectomy  in  a  given  case? 

First,  his  judgment  should  be  based  on  the  general  condition  of  the 
patient.  When  the  patient's  appetite  returns  and  his  sleep  becomes 


602  PROSTATIC  OBSTRUCTIONS 

normal,  when  his  temperature,  pulse  and  respiration  become  normal, 
and  when  the  renal  output  has  returned  to  its  normal  limits,  he 
should  consider  these  a  fair  index  of  the  general  physical  well-being  of 
the  patient. 

Second,  prostatectomy  is  not  safe  until  all  the  uremic  and  renal 
symptoms  have  disappeared.  A  moderate  amount  cf  albumin  in  the 
urine  is  no  contra-indication.  The  condition  of  the  blood-pressure 
is  a  valuable  index. 

Third,  the  phthalein  test  is  of  value  only  as  taken  in  connection 
with  other  signs.  In  the  first  place  one  must  consider  the  results  of  the 
phthalein  test  before  the  preliminary  drainage;  then  the  phthalein  test 
taken  on  the  second,  third  or  fourth  day,  and  again,  the  functional 
reaction  of  the  kidney  to  this  test  at  the  end  of  a  week  or  ten  days.  It  is 
a  mistake  to  rely  solely  upon  this  test,  especially  before  the  drainage 
has  been  instituted.  For  example,  the  test  may  show  excretion  of 
more  than  50  per  cent,  of  phthalein  in  the  first  two  hours  before  the 
preliminary  cystostomy,  but  the  reaction  may  drop  on  the  second  or 
third  day  after  relief  of  the  retention  of  urine  to  below  15  per  cent,  or 
even  lower,  which  is  a  true  indication  of  the  functional  capacity.  When, 
however,  the  period  of  depression  is  passed  and  the  output  returns  to 
50  per  cent,  after  the  retention  of  urine  has  been  relieved,  this  then 
becomes  a  fair  index  of  what  we  can  expect  the  kidney  to  do  after  the 
prostate  has  been  removed.  Of  far  greater  value,  however,  is  a  com- 
bined estimation  of  the  phthalein  output,  the  urea  excretion,  the  specific 
gravity  of  the  urine,  and  the  actual  amount  of  urine  excreted  in  twenty- 
four  hours,  taken  in  connection  with  a  determination  of  the  blood  urea 
and  blood  creatinin.  The  surgeon,  however,  must  always  take  into 
consideration  the  general  physical  condition  of  the  patient  before 
counselling  prostatectomy. 

A  persistently  low  phthalein  output  is  not  necessarily  a  contra- 
indication to  operation,  providing  that  these  other  clinical  evidences  of 
good  renal  function  are  present. 

Expectation  of  Cure. — The  primary  indication  is  the  reestablishment 
of  the  ability  of  the  individual  to  readily,  fully  and  painlessly  evacuate 
his  bladder.  With  regard  to  the  restoration  of  normal  function  it  must 
not  be  forgotten  that  the  statements  both  of  patients  and  of  surgeons 
should  always  be  considered  as  relative.  Prepossession  and  enthusiasm 
often  lend  a  rose  color  to  the  reports  of  results,  and  a  more  close  scrutiny 
of  the  conditions  may  often  elicit  information  as  to  attendant  infirmities 
which  modify  the  conclusions.  Nevertheless,  even  with  these  modi- 
fications, the  fulfilment  of  the  supreme  indication,  viz.,  the  removal  of 
the  urinary  obstruction,  is  a  sufficient  achievement  to  compensate 
for  the  presence  of  many  lesser  evils. 

The  patient  who  comes  to  us  in  the  early  stages  of  the  disease  before 
infection  has  taken  place  can  be  assured  today  that  the  result  of  removal 
of  his  prostate  will  be  a  full  restoration  of  the  bladder  to  its  normal 
function,  with  full  control  of  his  urine  and  the  ability  to  completely 
empty  his  bladder.  When  marked  deformity  of  the  outlet  has  taken 


ENLARGEMENT  OF  PROSTATE  603 

place  as  a  result  of  fibrous  changes,  the  end-result  is  usually  not  as 
satisfactory,  but  even  in  these  cases,  which  are  relatively  few  in 
number,  marked  improvement  in  the  obstructive  symptoms  results. 

The  patients  who  present  themselves  in  the  advanced  stages  of  the 
disease,  often  surprise  the  surgeon  by  the  completeness  of  their  return  to 
the  normal  condition.  The  extensively  trabeculated  bladder,  with  its 
hidden  recesses  the  seat  of  chronic  inflammatory  changes,  can  never  be 
expected  to  return  to  its  normal  state  again,  but  aside  from  the  evi- 
dences of  a  low-grade  chronic  cystitis,  the  patient  is  freed  from  his 
frequent  painful  urination  and  his  urinary  stasis.  Wherever  it  is  pos- 
sible to  remove  the  obstruction  completely  the  percentage  of  failure  is 
almost  nil.  The  so-called  failures  recorded  are  in  the  opinion  of  the 
writer  due  to  incomplete  operation. 

The  infirmities  which  sometimes  mar  the  results  are  impotence, 
urinary  incontinence,  epididymitis  and  crchitis,  fistulce,  stricture  of  the 
urethra. 

Impotence. — This  results  from  injury  to  or  removal  of  the  ejaculatory 
ducts.  It  is  less  likely  to  occur  when  the  operation  is  done  from  above, 
but  with  proper  care  the  segment  carrying  these  ducts  and  terminating 
in  the  verumontanum  can  usually  be  preserved  during  a  perinea!  enucle- 
ation.  It  is  a  surprising  fact  that  the  sexual  vigor,  if  present  before 
the  operation,  is  very  little  impaired  by  removal  of  the  hyperplastic 
portions  of  the  gland. 

Urinary  Incontinence. — This  is  of  rare  occurrence  as  a  result  of  pros- 
tatectomy. A  slight  defect  in  the  ability  to  retain  urine  in  the  bladder 
may  be  present  during  the  first  weeks  following  operation,  but  the 
sphincters  rapidly  regain  their  tone  and  full  control  of  the  urine  is 
established. 

In  our  own  series  of  cases  we  have  never  seen  incontinence  following 
a  perineal  or  suprapubic  prostatectomy.  I  believe  this  to  be  due  to  the 
fact  that  in  every  case  the  compressor  urethra?  muscle  has  been  care- 
fully preserved.  It  is  our  belief,  further,  that  in  the  majority  of  cases 
in  which  incontinence  of  urine  has  followed  an  operation,  it  has  been 
the  result  of  an  attempt  to  remove  a  prostatic  obstruction  where  the 
hyperplastic  masses  were  not  easily  enucleatable.  In  other  words,  it  is 
only  apt  to  occur  in  those  cases  where  there  is  no  distinct  defining 
capsule  and  the  overzeal  of  the  operator  makes  him  pass  beyond  the 
confines  of  the  prostate,  in  doing  which  he  injures  or  removes  a  portion 
of  the  muscle  which  controls  urination.  The  injury  or  removal  of  the 
internal  sphincter  does  not  have  any  effect  upon  the  actual  muscular 
control  of  urination,  as  has  been  frequently  proved  practically  where 
operations  have  involved  the  removal  of  the  internal  sphincter,  and  a 
full  control  of  the  urine  has  resulted. 

Epididymitis  and  crchitis  are  seldom  seen  unless  instrumentation  of 
the  urethra  is  employed  after  prostatectomy.  Rarely  does  epididymitis 
follow  the  operation  alone.  In  our  own  series  of  cases  epididymitis 
occurred  much  more  frequently  in  the  perineal  than  in  the  suprapubic 
sections.  In  a  few  cases  the  inflammation  extends  and  may  involve  the 


604  PROSTATIC  OBSTRUCTIONS 

loss  of  a  testicle,  and  may  cause  extensive  sloughing  of  the  tissues 
resulting  in  an  urethrorectal  fistula. 

Fistuloe. — Suprapubic  fistulse,  perineal  fistulse  and  recto-urethral 
fistulse  are  among  the  occasional  sequelae  of  operation  for  the  removal  of 
the  prostate.  They  occur  with  sufficient  frequency  to  make  their 
mention  necessary  in  any  complete  consideration  of  the  subject  of 
prostatectomy,  but  yet  so  rarely  as  to  have  very  little  practical  bearing 
on  the  prognosis  of  a  given  case.  In  the  absence  of  great  loss  of  sub- 
stance in  the  original  wound,  the  failure  of  a  suprapubic  or  perineal 
opening  to  close  is  usually  due  to  some  contraction  in  the  anterfor 
urethra,  and,  as  a  part  of  the  treatment  in  any  given  case,  the  surgeon 
should  secure  perfect  freedom  of  the  urethra!  lumen  throughout  its 
whole  extent. 

Recto-urethral  fistulse  may  result  either  from  an  accidental  tear 
through  the  anterior  wall  of  the  rectum  in  the  course  of  the  efforts  to 
expose  the  prostate  or  from  later  sloughing  consequent  upon  intense 
local  infection,  or  from  drainage  tube,  or  tampon  pressure.  The  very 
close  relation  of  the  prostate  and  the  rectum  at  once  suggests  the 
difficulty  of  separating  them  without  injury  to  the  rectum,  and  the 
possibility  of  such  injury  doubtless  had  much  to  do  in  discouraging 
earlier  attempts  on  any  general  scale  to  attack  the  prostate.  Fortu- 
nately, however,  between  the  capsule  of  the  prostate  and  the  underlying 
musculofibrous  external  coat  of  the  rectum  there  is  an  appreciable 
layer  of  loose  connective  tissue  which  forms  a  line  of  easy  cleavage,  so 
that  when  the  capsule  of  the  prostate  has  been  exposed,  the  further 
stripping  back  of  the  rectum  to  any  degree  that  may  be  necessary  is 
comparatively  free  from  danger  of  injury  to  the  bowel.  It  is  that 
portion  of  the  rectum  which  is  anterior  to  the  prostate,  and  which  is 
pulled  forward  toward  the  membranous  urethra  by  the  recto-urethralis 
muscular  fibers,  which  is  most  likely  to  be  the  seat  of  injury  when  the 
prostate  is  approached  from  the  perineum.  With  care  and  due  atten- 
tion to  the  anatomical  relations  of  the  structures  involved,  this  point  of 
danger  may  usually  be  avoided;  but  it  is  quite  conceivable  that  in 
occasional  instances  the  relations  and  texture  of  the  perineal  structures 
may  be  so  altered  by  fibrous  or  inflammatory  changes  as  to  make  the 
desired  detachment  and  pushing  back  of  the  rectum  without  injury  very 
difficult  to  accomplish.  That  such  injury  has  occurred  at  the  hands  of 
many  able  surgeons  is  a  matter  of  record,  and  it  is  not  unreasonable  to 
believe  that  not  all  the  instances  in  which  it  has  occurred  have  been 
published. 

In  our  earlier  experience  such  injury  to  the  rectum  occurred  twice  as 
the  result  of  misadventure  in  the  course  of  the  effort  to  expose  the 
prostate,  both  times  in  cases  of  small  fibrous  prostates  with  increased 
rigidity  of  the  recto-urethral  muscular  mass.  In  a  third  case  an  open- 
ing into  the  rectum  occurred  fourteen  days  after  operation,  as  the  result 
of  a  slough  due  to  wound  infection.  In  two  of  these  cases  the  fistula 
was  subsequently  completely  repaired  by  plastic  operation;  in  the 
third  case,  a  plastic  failed  to  close  the  fistula  and,  other  circumstances 


ENLARGEMENT  OF  PROSTATE  605 

having  prevented  its  repetition,  the  fistula  persisted  during  the 
remaining  two  and  a  half  years  during  which  the  patient's  life  was 
prolonged,  about  two-thirds  of  the  urine  passing  into  the  rectum  at  each 
urination,  requiring  the  man  to  sit  upon  the  stool  to  void  it. 

Urethral  stricture  does  not  seem  to  have  followed  to  any  serious 
degree  the  extensive  lacerations  and  removals  of  the  prostatic  urethra 
which  have  marked  many  of  the  operations  upon  the  prostate.  It  has 
been  frequently  the  case  that  the  entire  prostatic  urethra  has  been  taken 
away  with  no  subsequent  disturbance  of  the  urinary  functions. 
Extensive  tearing  away  of  the  prostatic  urethra  has  accompanied 
certainly  some,  and  probably  all,  of  the  extensive  enucleations  done 
by  the  suprapubic  route;  a  varying  degree  of  injury  to  the  floor 
and  lateral  walls  of  the  prostatic  urethra  attends  most  of  the  perineal 
methods  of  operation.  The  claims  of  many  operators  who  remove 
prostatic  masses  guided  by  the  sense  of  touch  alone,  that  very  limited 
injury  of  the  urethra  results  from  their  manipulations,  are  not  sustained 
by  our  knowledge  of  the  anatomical  conditions  of  the  parts.  The 
urethra  in  its  course  through  the  prostate  does  not  present  such  distinct 
layers  in  its  walls  as  are  found  in  its  membranous  and  penile  portions; 
nor  does  it  present  any  such  recognizable  layers  as  does  the  capsule  of 
the  gland  from  which  the  adenomatous  masses  of  an  enlarged  organcan 
be  readily  peeled  away.  It  consists  of  a  few  layers  of  columnar  epithe- 
lium resting  on  a  base  composed  of  connective  tissue  and  muscular 
fibers  which  are  directly  continuous  wTith  the  stroma  of  the  gland 
itself,  and  surround  and  support  the  score  and  more  of  ducts  to 
which  the  primary  lobule  outlets  converge,  and  which  open  upon  the 
floor  of  the  urethra,  and  which  are  also  lined  by  an  extension  of  the 
urethral  epithelium.  In  other  words,  the  submucous  and  muscular 
coats  belonging  to  the  urethra  in  other  parts  of  its  course  are  here 
replaced  by  prostatic  substance.  It  seems  to  the  writer  that  the 
laceration  of  the  urethral  wall  by  attempts  to  tear  out  more  or  less 
of  the  glandular  substance  external  to  it  can  be  prevented  only  by 
the  most  delicate  manipulation,  conducted  in  full  view  and  with 
the  assistance  of  careful  dissection  as  the  enucleation  approaches  the 
vicinity  of  the  urethral  wall.  The  periphery  of  these  prostatic  masses 
can  readily  be  enucleated  from  the  capsule  with  a  blunt  dissector  or 
with  the  finger-tip;  but  upon  the  urethral  side  of  the  mass  the  condition 
is  different.  These  masses  can  be  readily  torn  away,  it  is  true ;  but  the 
operator  who  thinks  that  in  effecting  this  he  leaves  the  prostatic  urethra 
intact  is  probably  mistaken.  More  emphatically  is  this  the  case  in  the 
presence  of  the  hard,  fibrous  prostate. 

It  may  be  well  therefore  to  accept  as  one  of  the  usual  accompani- 
ments of  prostatectomy,  a  very  considerable  laceration  and  loss  of 
substance  of  the  prostatic  urethra.  In  view  of  this,  the  fact  of  its 
regeneration  has  decided  surgical  interest.  When  the  roof  and  a  con- 
siderable portion  of  its  lateral  wall  is  left  after  the  enucleation  is 
completed,  it  is  natural  to  expect  that  the  conditions  insure  a  patent 
mucous-lined  canal  as  wound  healing  progresses;  in  those  other  cases  in 


606  PRO  STATIC  OBSTRUCTIONS 

which  nearly  complete  enucleation  of  the  whole  gland  en  masse,  bringing 
with  it  a  considerable  segment  of  the  whole  circumference  of  the  urethra, 
is  effected  by  attack  from  within  the  bladder,  there  remains  an  irregular, 
but  in  general  a  funnel-shaped,  cavity,  into  which  the  bladder  mucosa 
must  prolapse,  and  as  the  process  of  repair  progresses,  furnishes  an 
advancing  line  of  epithelium  to  cover  the  raw  surface.  From  the  end  of 
the  membranous  urethra  likewise  a  similar  epithelial  growth  may  con- 
tribute to  the  ultimate  result;  from  the  ducts  and  lumina  of  any  of  the 
gland  substance  that  may  have  escaped  the  surgical  attack  an  addi- 
tional source  of  epithelium  may  be  supplied.  This  may  explain  why 
speedy  regeneration  of  an  adequate  epithelium-lined  canal  through  the 
area  formerly  occupied  by  the  prostate  has  been  demonstrated  by  abun- 
dant clinical  experience.  The  very  natural  apprehension  entertained 
by  many  that  intractable  stricture  would  be  a  common  sequel  to  these 
operations  has  not  been  realized.  In  order  to  secure  this  immunity 
from  later  stricture,  it  would  seem  that  the  urethra!  injury  must  be 
restricted  to  the  prostatic  portion  of  the  urethra.  It  would  seem  also 
a  sound  surgical  procedure  in  all  cases  to  place  a  good-sized  rubber 
drainage  tube  in  the  bladder  through  the  prostatic  hiatus  during  the 
early  days  after  the  operation,  to  be  replaced  later,  possibly  for  a  week 
or  more,  by  a  catheter  a  demeure;  this,  in  addition  to  the  advantages  of 
drainage,  answers  the  purpose  of  favoring  and  controlling  the  formation 
of  a  suitable  channel,  along  which  the  process  of  epithelial  proliferation 
should  extend.  The  occasional  use  of  a  full-sized  sound  may  be  adopted 
as  a  substitute  for  the  catheter  for  a  time  in  the  subsequent  treatment. 
The  Surgical  Problem. — To  state  the  case  in  its  simplest  terms  the 
problem  presented  in  obstructive  lesions  of  the  prostate  is: 

1.  To  provide  a  free  exit  for  the  urine  from  the  bladder. 

2.  To  permanently  remove  the  obstruction  at  the  neck  of  the 
bladder. 

3.  To  preserve  the  sphincter  vesicse,  and  if  possible,  the  ejaculatory 
ducts. 

4.  To  prevent  postoperative  shock  and  hemorrhage. 

5.  To  prevent  infection  and  sloughing. 

6.  To  secure  rapid  healing  of  wound  and  the  reestablishment  of  the 
normal  functions. 

The  Choice  of  Operation. — Intra-urethral  methodsof  operation  are  indi- 
cated in  the  cases  of  obstruction  due  to  submucous  fibrosis;  bar  forma- 
tions of  inflammatory  origin,  and  obstructions  due  to  hyperplasia  of  the 
suburethral  and  subtrigonal  glands.  In  the  remaining  cases  there  are 
but  two  methods  of  operation  to  be  considered,  namely,  perineal  and 
suprapubic-transvesical  prostatectomy.  So  much  has  already  been 
written  concerning  the  relative  merits  of  each  that  a  full  discussion 
of  the  subject  is  not  necessary.  It  is  safe  to  say  that  the  majority  of 
surgeons  have  adopted  the  suprapubic  transvesical  method.  In  the 
hands  of  a  few  specially  trained  men  there  is  practically  no  choice 
between  the  two  methods,  judging  from  the  mortality  records,  and 
the  character  of  the  end-results.  But  this  does  not  hold  good  when  we 


ENLARGEMENT  OF  PROSTATE  607 

consider  the  results  of  the  operation  in  the  hands  of  the  general  surgeon 
to  whom  the  major  portion  of  the  work  comes. 

Perineal  prostatectomy  is  an  operation  for  the  expert  only.  Supra- 
pubic  prostatectomy  is  an  operation  per  se  which  can  be  easily  per- 
formed by  the  majority  of  surgeons.  In  the  latter  operation  the  chances 
of  accident  are  less  and  the  certainty  of  completely  removing  the 
obstruction  is  greater  than  when  perineal  prostatectomy  is  attempted 
by  a  surgeon  who  is  not  specially  trained  in  the  surgery  of  this  region. 
Many  men  encouraged  by  the  brilliant  results  of  a  few  who  popu- 
larized the  perineal  operation,  attempted  the  operation  and  brought 
discredit  to  it  by  their  failures.  The  same  is  true  to  a  lesser  degree 
of  the  suprapubic  operation.  The  fact  is  that  success  in  remov- 
ing prostatic  obstructions  depends  upon  a  fundamental  knowledge  of 
the  pathology  of  the  disease,  not  only  as  it  affects  the  prostate  itself, 
but  more  especially  as  it  affects  the  bladder  and  ureters  and  kidneys. 
The  mortality  percentage  in  a  given  series  of  cases  does  not  depend 
upon  the  particular  type  of  operation  employed,  but  it  does  depend 
upon  the  individual  surgeon  who  performs  the  operation,  his  pre- 
operative  study  of  the  case,  his  ability  to  anticipate  the  dangers  before 
they  arise,  and  his  skill  in  meeting  the  emergencies  as  they  occur. 

Some  expert  urologists  who  operate  upon  the  majority  of  their  cases 
by  the  suprapubic  route  still  employ  the  perineal  route  in  those  cases 
where  the  obstruction  is  caused  by  a  small  fibrous  prostate.  Practically 
all  surgeons  agree  that  the  suprapubic  operation  is  preferable  in  those 
cases  in  which  there  is  a  massive  intravesical  overgrowth  of  the  gland. 
Many  surgeons  perform  suprapubic  prostatectomy  in  two  stages,  the 
first  operation  consisting  of  a  cystostomy  with  drainage  of  the  bladder ; 
the  second  operation,  enucleation  of  the  prostate  through  the  existing 
,  cystostomy  opening.  This  is  the  method  preferred  by  the  writer. 
Other  surgeons  complete  the  operation  in  one  stage.  Experience  and  a 
proper  consideration  of  the  individual  case  should  always  guide  the 
operator. 

Removal  of  Obstructing  Growths  per  Urethram.* — Attempts  to  remove 
the  obstruction  at  the  neck  of  the  bladder  by  means  of  instruments 
introduced  and  operated  through  the  urethra  date  back  for  over  a  cen- 
tury. The  sum  total  of  the  experience  gained  during  that  period  and 
especially  during  the  past  twenty  years  is,  that  no  permanent  relief  can 
be  gained  excepting  in  the  cases  of  the  irregular  forms  of  obstruction 
which  we  have  described  under  the  headings,  Submucous  Fibrosis,  Bar 
Formations  Due  to  Chronic  Inflammatory  Changes,  and  Obstructions 
Due  to  Hyperplasia  of  the  Suburethral  and  Subtrigonal  Glands. 

In  dealing  with  these  types  we  have  a  choice  of  various  methods: 
Destruction  of  the  obstruction  by  means  of  the  galvanocautery  knife, 
or  the  high-frequency  spark,  or  actual  removal  of  the  tissue  by  means 
of  an  instrument  which  punches  out  the  tissue.  Mercier,  in  1839, 
devised  the  first  instrument  for  actually  excising  portions  of  the  growth, 

*  For  an  extended  history  and  description  of  this  method  see  Deaver's  "Enlargement 
of  the  Prostate."  Blakiston's  Son  <S?  Co.,  Philadelphia,  1905,  p.  176, 


608  PROSTATIC  OBSTRUCTIONS 

improving  his  technic  and  adding  a  blade  for  simply  cutting  through  a 
median  obstruction.  Bottini,  in  1874,  introduced  his  method  of  division 
and  incision  of  the  prostatic  obstruction  by  means  of  a  galvanocautery 
instrument,  hoping  by  this  method  to  avoid  the  hemorrhage  which  was 
so  dangerous  a  complication  of  the  Mercier  method.  These  surgical 
procedures  were  extensively  tried,  modified,  and  improved,  and  were 
the  methods  of  choice  until  the  present  technics  of  perineal  and  supra- 
pubic  prostatectomy  were  introduced ;  then  it  was  demonstrated  that 
the  operation  of  complete  removal  of  the  diseased  portion  of  the  prostate 
was  just  as  safe  as  these  partial  expedients,  and  the  results  were  far 
more  satisfactory  and  lasting.  The  result  has  been  that  most  of  these 
operations  conducted  per  urethram  have  been  discarded  in  the  cases  of 
true  hypertrophy  of  the  prostate.  There  still  is  a  limited  field,  i.  e., 
in  the  irregular  forms  of  obstruction,  for  the  partial  excision  and  electric- 
spark  destruction. 

H.  H.  Young,17  in  1909,  devised  an  instrument  very  much  like  the 
original  Mercier  tube,  which  he  uses  in  these  irregular  forms  of  obstruc- 
tion. The  instrument  consists  of  a  long  sheath  with  a  curved  beak 
suitable  for  introduction  through  the  urethra  into  the  bladder.  On  the 
surface  opposite  the  concavity  of  the  tube  and  proximal  to  the  curve 
there  is  an  opening,  which  is  closed,  during  the  introduction  of  the 
instrument,  by  an  obturator  (Fig.  274). 


FIG.  274. — Young's  urethroscopic  median  bar  excisor.     (Randall.) 

Technic  of  the  Young  Punch  Operation. — The  patient  is  carefully  pre- 
pared as  for  any  major  operation.  He  is  then  placed  on  the  operating 
table  in  the  lithotomy  position,  the  urethra  and  bladder  cocainized, 
and  the  bladder  filled  with  water.  The  instrument  is  then  introduced 
until  the  beak  enters  the  bladder.  The  obturator  is  withdrawn  and  the 
posterior  urethra  is  illuminated  by  reflected  light.  Then  the  instrument 
is  advanced  until  the  fenestrum  slips  over  and  engages  the  obstructing 
mass  or  bar  (Fig.  275),  which  partly  fills  the  lumen  of  the  tube  at  this 
point.  A  second  tube,  with  cutting  edge,  is  then  passed  in  and  cuts  out 
or  punches  out  the  tissue  which  protrudes  into  the  lumen  of  the  tube. 
The  first  punch  is  made  posteriorly.  Then,  if  necessary,  other  pieces  of 
tissue  are  excised  on  the  lateral  aspects  of  the  opening,  until  the 
operator  is  satisfied  that  he  has  made  a  sufficiently  large  opening  to 
permit  the  free  passage  of  the  urine.  The  bladder  is  then  thoroughly 
irrigated  with  hot  solutions,  and  a  large  catheter  is  introduced  and  left 
in  place,  through  which  the  bladder  is  repeatedly  washed  to  prevent 
the  accumulation  of  blood  clots. 


ENLARGEMENT  OF  PROSTATE 


609 


This  method  has  been  employed  by  Young  in  a  large  series  of  cases, 
and  he  reports  universally  good  results  in  the  cases  of  "median-bar 
formation,"  but  condemns  its  use  in  the  cases  of  true  prostatic  hyper- 
trophy. It  is  not  without  its  dangers,  however,  and  should  be  employed 
with  caution.  Other  operators  report  cases  in  which  the  hemorrhage 
attending  and  following  it  have  necessitated  opening  the  bladder  to 
control  the  bleeding. 


FIG.  275. — Young's  instrument  in  operation.     (Randall.) 

The  High-frequency  Spark  Operation. — This  form  of  treatment  is 
applicable  in  the  same  class  of  cases  as  the  Young's  punch  operation. 
The  spark  operation  is  less  trying  for  the  patient,  and  eliminates  almost 
entirely  the  danger  of  hemorrhage.  The  patient  is  prepared  as  for  a 
cystoscopic  examination.  A  catheterizing  cystoscope  of  small  size,  or  a 
cysto-urethroscope  is  used.  With  the  instrument  in  place,  the  obstruct- 
ing mass  is  brought  into  view  and  the  electric  wire  is  advanced  until  it 
engages  the  tissue.  Then  the  spark  is  applied  for  a  period  of  from 
twenty  to  thirty  seconds,  or  until  the  tissue  shows  destructive  effect  of 
the  spark,  dependent,  of  course,  on  the  strength  of  the  current.  The 
spark  is  applied  along  parallel  lines,  reaching  well  across  the  obstruc- 
tion. It  is  best  to  be  cautious  with  the  first  application,  doing  too  little 
rather  than  too  much.  After  a  period  of  two  weeks,  the  cystoscope 
is  again  introduced,  the  effect  observed,  and  further  treatment  applied. 
Considerable  improvement  should  follow  after  the  fourth  or  fifth 
treatment. 

Bugbee,1  who  has  treated  a  number  of  cases  by  this  method,  has 
published  the  following  conclusions: 

The  residual  urine  has  been  eliminated  in  all  cases  of  median-bar 
obstructions,  as  well  as  those  due  to  cicatrix  and  chronic  inflammation 
of  the  vesical  neck. 

Partial  relief  was  obtained  in  cases  of  incomplete  prostatectomies 
with  nodules  of  prostate  remaining  about  the  vesical  neck. 
M  TI    i — 39 


610  PROSTATIC  OBSTRUCTIONS 

Of  the  patients  with  glandular  hyperplasia,  nine  in  number,  three 
have  died  of  intercurrent  disease;  two  are  symptomatically  relieved; 
three  are  still  under  treatment.  In  eight  of  the  nine  treated,  the 
residual  urine  was  lessened.  In  one  case  there  was  no  improvement. 

The  cases  of  lateral-lobe  enlargement  have  shown  little  improvement. 
These  results  bear  out  the  belief  of  the  writer  that  the  high-frequency 
current  should  be  reserved  for  the  cases  of  submucous  fibrosis  and 
enlargements  due  to  chronic  inflammatory  changes  alone. 

Transvesical  Prostatectomy. — Transvesical  prostatectomy  has  been 
employed  for  many  years  with  varying  degrees  of  success.  Its  uni- 
versal acceptance  as  a  method  for  enucleation  of  the  prostate  has 
been  delayed  by  several  unpleasant,  and  often  dangerous,  features 
which  have  resulted  from  imperfect  technic.  Chief  among  these 
factors  have  been: 

1.  The  discomfort  of  the  patient  due  to  continuous  urinary  leakage 
from  the  suprapubic  wound. 

2.  The  sloughing  and  infection  of  the  wound. 

3.  Incomplete  control  of  hemorrhage. 

4.  Confinement  in  bed. 

5.  Prolonged  urinary  leakage. 

6.  Long-continued  urinary  fistulse. 

Since  these  objections  have  been  overcome  by  the  employment 
of  a  special  technic,  transvesical  prostatectomy  has  become  more 
popular  than  perineal  prostatectomy.  Since  a  suprapubic  cystostomy 
is  usually  done  as  the  first  step  of  a  transvesical  prostatectomy, 
division  of  the  operation  into  two  stages  has  naturally  suggested  itself 
and  is  now  employed  by  many  surgeons  in  preference  to  preliminary 
catheterism  and  later  transvesical  prostatectomy.  A  discussion  of  the 
merits  of  these  steps  has  already  been  given. 

In  those  cases  in  which  the  operation  of  transvesical  prostatectomy  is 
completed  in  one  stage  the  technic  of  the  cystotomy  is  exactly  the  same 
as  when  a  cystostomy  is  performed,  with  the  exception  of  the  closure 
of  the  wound.  Therefore  the  two  will  be  described  together. 

The  writer  prefers  the  two-stage  operation  in  practically  every  case 
of  glandular  hyperplasia  of  the  prostate  for  the  following  reasons : 

1.  It  permits  of  renal  decompression  with  the  least  risk.9 

2.  It  provides  complete  urinary  drainage  without  any  urinary  leak- 
age.    The  result  is  a  dry  wound  and  allows  the  patient  to  be  out  of  bed 
within  twenty-four  hours  after  the  cystostomy. 

3.  Primary  union  of  the  suprapubic  wound  is  secured  around  the 
opening  into  the  bladder  through  which  the  prostate  may  be  enucleated, 
thus  excluding  the  tissues  of  the  prevesical  and  perivesical  spaces  from 
the  operative  field  and  preventing  infection  and  extravasation  of  urine. 

With  the  drainage  tube  in  place  and  the  urine  entirely  controlled,  an 
indefinite  period  may  be  allowed  for  the  patient  to  recover  from  his  stage 
of  depression  and  a  time  may  be  chosen  for  the  prostatectomy  which  is 
most  favorable  for  the  patient.  Often  without  further  incision  for  the 
use  of  any  instrumentation  the  enucleation  of  the  prostate  may  be 


ENLARGEMENT  OF  PROSTATE 


611 


accomplished  through  the  opening  already  provided,  thereby  greatly 
diminishing  the  possibilities  of  surgical  shock  and  limiting  the  area  in 
which  infection  may  develop. 

Suprapubic  Cystostomy. — Cystostomy  is  employed  either  as  a  first 
stage  of  the  two-step  operation,  or  as  a  preliminary  to  transvesical  pros- 
tatectomy. The  operation  is  performed  under  local  anesthesia. 

Preparation  of  the  Patient. — The  usual  catharsis  is  given  forty-eight 
hours  previous  to  the  day  of  operation.  No  catharsis  or  enema 'is 
given  within  twenty-four  hours  of  the  operation.  The  field  of  opera- 


FIG.  276. — Infiltration  of  bladder  with  novocain.     (Lower.) 

tion  is  prepared  by  shaving  the  parts  and  cleansing  them  with  soap 
and  water  the  day  before  operation.  Just  before  the  operation  is 
commenced  iodine  is  applied  to  the  skin. 

In  emergency  cases  the  area  is  shaved,  Harrington's  solution  is 
applied,  followed  by  washing  with  alcohol. 

Special  efforts  are  made  to  inspire  the  confidence  of  the  patient  before 
the  operation.  Examinations  are  made  with  the  utmost  gentleness. 
The  night  before  operation  the  patient  is  given  30  grains  of  sodium 
bromide  and  this  is  repeated  on  the  morning  of  the  operation.  In  many 


612 


PROSTATIC  OBSTRUCTIONS 


cases  morphin,  grain  |,  combined  with  atropin,  grain  yfg-,  is  given 
by  hypodermic  injection  half  an  hour  before  the  operation.  Many 
urologists  object  to  the  use  of  morphin  in  these  cases,  but  the  writer 
feels  that  their  objections  are  not  sustained.  Wherever  possible  the 
principles  of  anoci-association  are  employed  during  the  performance 
of  the  operation. 

This  is  advocated  both  during  the  cystotomy  and  later  in  enucleat- 
ing the  prostate.     Lower's4  technic  is  as  follows : 


FIG.  277. — Deep  infiltration  along  edges  of  capsule  of  prostate  before  removal.      (Lower.) 

1.  An  hour  before  the  operation  the  patient  is  given  a  hypodermic 
injection  of  morphin  and  scopolamin,  the  size  of  the  dose  depending 
upon  the  age  of  the  patient. 

2.  Immediately  before  the  operation  the  bladder  is  irrigated  and 
60  to  90  c.c.  of  a  5  per  cent,  solution  of  alypin  is  injected  through  the 
catheter.     The  catheter  is  clamped  and  both  catheter  and  solution  are 
allowed  to  remain. 

3.  The  bladder  is  approached  in  the  usual  way  except  that  the  skin 
incision  and  every  division  of  tissue  is  preceded  by  a  thorough  infiltra- 
tion with  novocain  in        -  solution. 


ENLARGEMENT  OF  PROSTATE 


613 


4.  When  the  bladder  is  exposed  it  is  elevated  with  curved  hooks 
and  thoroughly  infiltrated  with  novocain  solution  (Figs.  276  and  277). 

Technic  of  Suprapubic  Cystostomy. — The  skin  incision  begins  about 
one  inch  above  the  symphysis  and  is  continued  in  a  vertical  direction 
toward  the  umbilicus  for  about  four  inches.  The  fat  and  fascia  are 
divided  with  a  knife  and  the  recti  muscles  are  separated  by  the  finger; 
the  remaining  fascia  and  prevesical  tissues  are  easily  separated.  At 
this  point  the  bladder  is  well  filled  with  sterile  water  through  a  catheter 
introduced  by  the  urethra.  If  it  is  not  possible  to  introduce  a  catheter 
without  undue  force,  it  is  not  attempted. 


FIG.  278. — Showing  the  surgical  problem.  Special  attention  should  be  directed  to 
A,  the  fold  of  peritoneum  in  its  relation  to  the  symphysis  when  the  bladder  is  con- 
tracted. B,  the  raising  up  of  the  peritoneal  fold  when  the  bladder  is  dilated.  The 
relation  of  A  and  B  to  the  symphysis  is  quite  variable  and  in  some  instances  is  fixed  at 
the  level  of  the  symphysis. 

With  the  bladder  full  the  finger  is  introduced  into  the  wound  until  the 
under  surface  of  the  symphysis  pubis  is  reached ;  then  the  finger  covered 
with  gauze  is  slowly  swept  upward,  gradually  lifting  the  tissues  away 
from  the  anterior  surface  of  the  bladder,  at  the  same  time  forcing  the 
peritoneal  fold  upward.  This  is  of  great  importance  because  the  peri- 
toneal fold  frequently  descends  low  and  lies  over  the  anterior  wall  of 
the  bladder  where  it  is  desired  to  expose  it  (Figs.  278  and  279).  After 
the  bladder  wall  has  been  cleared  it  will  be  recognized  by  the  tortuous 
dilated  veins  presenting  on  its  surface,  extending  upward  in  a  fan  shape. 


614 


PROSTATIC  OBSTRUCTIONS 


Also  the  appearance  of  the  thick  muscle  bundles  of  the  bladder  wall  is 
characteristic.     When  the  finger  is  removed  the  peritoneal  fold  will 


FIG.  279. — Second  step,  freeing  anterior  wall  of  the  bladder,  preparing  it  for  incision. 
Finger  has  been  swept  upward  from  symphysis  along  anterior  face  of  the  bladder 
carrying  with  it  peritoneal  fold  P.  If  finger  is  removed  from  the  wound  at  this  point,  the 
peritoneal  reflexion  will  be  seen  forcing  its  way  downward  with  each  respiration  of  the 
patient. 


\ 


FIG.  280. — The  bladder  wall  is  seen  exposed  and  the  position  of  the  incision  is  indi- 
cated near  the  fold  of  the  peritoneum.  The  two  stay  sutures  are  in  place  and  hold  the 
bladder  wall  up.  As  soon  as  these  sutures  have  been  introduced  the  fluid  is  withdrawn 
from  the  bladder. 

bulge  downward.     Great  care  must  be  exercised  in  pushing  back  the 
peritoneum,  for  it  is  easily  torn.     This  accident  has  occurred  to  the 


ENLARGEMENT  OF  PROSTATE 


615 


writer,  but  no  untoward  symptoms  follow  the  injury  if  the  wound  is 
immediately  closed. 

When  the  bladder  wall  is  properly  bared,  retractors  are  introduced, 
two  lateral  ones  to  hold  back  the  muscles,  and  one  in  the  upper  angle  of 
the  wound  to  hold  back  the  peritoneal  fold.  When  all  is  in  readiness, 
two  retaining  sutures  are  introduced  into  the  bladder  wall  (Fig.  280), 
about  an  inch  apart  on  either  side  of  the  point  where  the  bladder  is  to  be 
incised.  This  point  is  chosen  at  the  uppermost  limit  of  the  bladder 
near  the  peritoneal  fold.  Before  the  bladder  is  opened  the  fluid  is 
allowed  to  flow  out  through  the  urethral  catheter.  The  button  drain- 
age tube  (Figs.  281  and  282)  is  held  ready  for  use.  Then  the 
bladder  is  held  up  and  steadied  by  the  stays,  or  clamps  if  preferred, 
and  an  opening  is  made  at  the  point  chosen.  The  finger  is  inserted 
through  the  opening,  the  interior  of  the  bladder  explored,  foreign  bodies, 
calculi,  etc.,  are  removed  and  the  character  and  size  of  the  prostate  is 


Pilc'her 

button 

drainagetube 


FIG.  281. — de  Pezzer  catheter. 


FIG.  282. — The  Pilcher  modification. 


determined.  When  the  finger  is  withdrawn  the  button  drainage  tube 
is  immediately  inserted  and  fixed  in  place  either  by  a  purse-string  suture 
of  chromic  gut  or  silk  or  by  tying  the  stay  sutures  around  the  tube 
(Fig.  283) .  If  it  is  undesirable  to  empty  the  bladder  the  tube  is  plugged 
with  a  cork;  otherwise  it  is  allowed  to  drain  as  it  will.  At  times  small 
vessels  in  the  bladder  wall  are  injured.  These  should  be  clamped  or 
ligated. 

The  Drainage  Opening. — One  should  be  perfectly  satisfied  with  the 
position  of  the  opening  in  the  bladder  before  completing*  this  step 
of  the  operation.  If  after  exploration  the  opening  is  found  to  be 
in  the  lower  half  of  the  bladder,  which  would  bring  it  too  near  the 
urethral  outlet,  it  is  better  to  reintroduce  the  finger  in  order  to  better 
outline  the  upper  limits  of  the  bladder  (Fig.  284),  and  with  this  as  a 
guide,  slowly  dissect  back  the  peritoneum  and  make  a  new  opening 
higher  up  (Fig.  285).  Then  the  first  opening  should  be  closed  with  a 


616 


PROSTATIC  OBSTRUCTIONS 


double  layer  of  chromic  gut  (Fig.  286).  In  this  way  we  can  almost 
certainly  assure  ourselves  of  a  rapid  closure  of  the  suprapubic  wound, 
provided  that  all  of  the  obstructing  prostate  is  removed. 

Being  satisfied  with  the  fixation  of  the  tube  and  its  position,  and 
after  testing  it  to  see  that  it  drains  freely,  the  prevesical  space  is 
closed  by  catgut  suture,  obliterating  all  dead  space  between  the 
symphsis,  the  fascia  and  the  bladder  wall.  Then  the  fascia  and  muscles 
are  brought  together  below  the  tube  (Fig.  287)  by  interrupted  chromic 
gut  sutures  leaving  the  tube  high  up  in  the  wound.  The  fascia  and 
muscles  protecting  the  peritoneum  are  likewise  sutured  with  interrupted 


FIG.  283. — Shows  the  way  in  which  the  button  drainage  tube  is  fixed  into  the  bladder 
wound — the  stay  suture  from  one  side  being  tied  on  the  opposite  side  of  the  tube  includ- 
ing some  of  the  bladder  wall,  and  the  one  from  the  other  side  tied  in  a  similar  manner. 
These  will  hold  the  tube  firmly  in  place.  A  purse-string  suture  is  used  for  the  same 
purpose. 

chromic  gut  sutures,  leaving  only  a  little  space  not  closed  around  the 
tube  (Fig.  288).  Then  the  skin  is  brought  together  by  interrupted  silk 
sutures  (Fig.  289).  The  drainage  tube  should  be  further  steadied  by 
fixing  it  to  the  skin  by  means  of  an  adhesive  strip  (Fig.  290) .  Then  dry 
gauze  dressings  are  applied  and  held  in  place  by  strips  of  adhesive  tape. 
(Fig.  290). 

The  urethral  catheter  should  be  removed. 

If  during  the  course  of  the  operation  the  local  anesthesia  is  not  suffi- 
cient to  deaden  pain,  a  general  anesthetic  should  be  given.  The  writer 
never  uses  spinal  anesthesia  in  these  cases.  Some  operators,  however, 


ENLARGEMENT  OF  PROSTATE 


617 


prefer  it.  The  indications  for  its  use  are  similar  to  those  for  other 
operations  on  the  same  subjects. 

Following  the  application  of  the  dressings  the  patient  is  returned  to 
his  bed. 

The  Convalescent  Period. — Management  of  the  Urinary  Drainage. — 
As  soon  as  the  patient  reaches  his  room  the  stopper  is  removed  from 
the  drain  pipe  and  the  bladder  emptied.  If  there  has  been  only  a 
small  amount  of  residual  urine  continuous  drainage  is  allowed.  If 


FIGS.  284  and  285. — Method  of  preparing  a  new  site  for  drainage  opening  when  one 
has  found  the  first  opening  in  the  bladder  too  near  urethral  orifice.  Finger  in  bladder 
locates  peritoneal  reflexion  and  with  knife  and  sponge  the  peritoneal  attachments  are 
gradually  reflected  from  bladder  and  new  site  selected. 


there  has  been  a  marked  and  long-standing  distention  of  the  bladder, 
continuous  draining  should  be  avoided,  the  stoppered  drain  being 
opened  at  intervals  of  one  or  two  hours  as  the  case  demands. 

No  attempt  is  made  during  the  first  three  or  four  days  following  the 
operation  to  wash  or  medicate  the  bladder. 

The  most  marked  reaction  which  follows  the  operation  will  become 
evident  from  the  second  to  the  fifth  day  after  suprapubic  cystostomy. 
The  patient,  however,  is  in  the  best  possible  condition  to  withstand  this 


618 


PROSTATIC  OBSTRUCTIONS 


FIG.  286.  —  First  incision 
closed  by  suture.  Second 
incision  a  stab  incision 
through  which  button  drain- 
age tube  is  inserted.  First 
incision  is  carefully  closed 
over  by  prevesical  tissues.  FIG.  287.— Sutures  set  through  muscle  and  fascia  layers. 


>ym 


FIG.  288. — Fascia  and  muscles  sutured.  FIG.  289. — The  skin  suture. 


ENLARGEMENT  OF  PROSTATE 


619 


depression,  for  there  has  been  practically  no  loss  of  blood,  no  general 
anesthetic,  and  no  special  pain,  all  of  which  factors  tend  to  decrease 
the  resisting  powers  of  the  organism. 


FIG.  290. — Method  of  securing  button  drainage  tube  in  abdominal  wound  to  prevent 
its  slipping  out  or  in,  and  consists  of  a  simple  strip  of  adhesive  plaster  one  piece  of  which 
crosses  the  abdomen  and  the  other  piece  encircles  the  drainage  tube  and  then  is  attached 
to  the  abdomen.  The  condition  finally  secured  is  shown  in  Fig.  291. 


FIG.  291. — de  Pezzer  catheter  in  place  after  suprapubic  cystostomy.  Button  of  the 
catheter  fits  snugly  and  is  far  superior  to  the  ordinary  drainage  tube  inasmuch  as  it 
does  not  permit  any  rough  or  sharp  surface  to  irritate  the  prostate  or  the  bladder  wall. 
This  idea  was  first  suggested  to  me  by  Rovsing  and  is  the  method  which  he  follows. 


620  PROSTATIC  OBSTRUCTIONS 

If  the  technic  of  the  operation  has  been  carefully  followed,  there  will 
result  a  cystostomy  opening  in  which  the  button  drainage  tube  fits 
snugly,  and  being  securely  held  in  place  prevents  any  leakage  around 
the  tube  and  at  the  same  time  completely  empties  the  bladder. 

It  has  been  the  experience  of  the  writer  in  employing  this  technic 
that  primary  union  of  the  wound  is  secured  in  practically  every  case, 
even  where  an  extensive  infection  of  the  bladder  exists.  The  special 
features  which  recommend  the  adoption  of  this  technic,  as  first  described 
by  the  writer,10  are  that  primary  union  of  the  wound  is  secured  with 
complete  control  of  the  urine;  further,  that  the  prevesical  and  peri- 
vesical  spaces  have  been  eliminated  from  the  surgical  problem  and  half 
of  the  operation  of  transvesical  prostatectomy  has  been  completed 
without  the  employment  of  general  anesthesia  and  with  freedom  from 
surgical  shock. 

Enucleation  of  the  Prostate. — Many  surgeons  still  proceed  with  enucle- 
ation  of  the  prostate  at  the  time  of  the  primary  operation  and  the 
method  of  its  accomplishment  is  practically  the  same  whether  it  is 
employed  as  a  primary  operation  or  as  a  second  step  following  recovery. 

Preparation  for  the  Second  Stage. — When  the  time  for  removing  the 
prostate  has  arrived,  the  patient  is  prepared  for  operation  as  before. 
All  unnecessary  catharsis,  etc.,  on  the  previous  day  is  avoided.  The 
patient  is  placed  on  the  table  and  iodine  is  applied  to  the  skin  around 
the  drainage  tube. 

Anesthesia. — When  all  is  ready  the  anesthesia  is  begun.  At  our 
clinic  we  prefer  ether  administered  by  the  drop  method.  Here  again  the 
principles  of  anoci-association  should  be  employed,  and  Lower  prefers 
nitrous  oxygen  administered  by  an  expert  anesthetist.  To  diminish 
the  shock  the  finger  is  introduced  into  the  suprapubic  opening  and  with 
this  as  a  guide  the  needle  of  the  syringe  containing  the  novocain  is 
inserted  into  the  prostate  and  the  infiltration  is  done  along  the  edges 
of  the  capsule  and  into  the  gland  itself  (Fig.  277) . 

In  cases  in  which  the  period  of  depression  following  the  first  opera- 
tion is  short,  i.  e.,  from  one  to  two  weeks,  it  is  not  necessary  to  use 
any  instruments  to  enlarge  the  drainage  opening;  the  silk  skin  sutures 
are  still  in  place  and  should  remain.  Where  the  skin  sutures  have  cut 
through  it  is  sometimes  wise  to  reinsert  heavy  silk  stay  sutures  to 
splint  and  keep  the  wound  from  tearing  open  during  the  manipula- 
tions necessary  for  enucleating  the  prostate.  Where  a  long  interval  is 
necessary  between  the  first  and  second  operation,  it  is  frequently  of 
advantage  to  enlarge  the  opening. 

Enlarging  the  Suprapubic  Opening. — This  is  done  as  shown  in  Fig. 
292  by  three  radiating  incisions  extending  on  each  side  of  and  down- 
ward from  the  opening.  These  incisions  are  not  necessarily  more  than 
an  inch  in  length  and  are  all  carried  through  the  subcutaneous  fat  to 
the  sheath  of  the  rectus  muscle. 

Making  the  Approach  to  the  Prostate  Easier.— If  the  patient  is  very 
stout  and  the  thickness  of  the  abdominal  wall  leaves  the  prostate  out  of 
our  reach,  it  is  desirable  to  remove  sufficient  subcutaneous  fat  to  allow 


ENLARGEMENT  OF  PROSTATE 


621 


the  hand  to  rest  directly  against  the  sheath  of  the  recti  muscles.  This 
reduces  the  intervening  space  between  the  hand  and  the  prostate  and 
makes  the  distance  for  the  finger  within  the  bladder  about  the  same  in 
all  cases.  In  cases  where  the  approach  is  still  too  constricted  to  allow 
of  complete  control  of  the  field  of  operation,  the  wound  is  enlarged  by 
carrying  the  two  lateral  incisions  deeper  through  the  sheath  of  the 
recti  muscles.  Thus,  any  degree  of  exposure  can  be  obtained  with- 
out reopening  the  prevesical  spaces.  The  incisions  are  not  extended 
upward  on  account  of  the  danger  of  injury  to  the  peritoneum. 


FIG.  292. — Enlarging  the  suprapubic  opening  after  cystostomy  where  a  nearer 
approach  to  the  prostate  is  desired.  Note  that  there  are  two  lateral  incisions  and  one 
toward  the  pubis  extending  only  through  the  fat  layer.  In  doing  an  enucleation  of  the 
prostate  the  skin  sutures  remain  in  place.  The  wound  is  not  enlarged  upward  because 
of  the  danger  of  opening  the  peritoneal  cavity. 

The  Enucleation. — With  the  approach  to  the  prostate  provided  for, 
the  enucleation  of  the  enlarged  portions  of  the  gland  is  accomplished  by 
entering  the  index  finger  of  the  one  hand  (or  in  difficult  cases  the  index 
and  second  finger)  into  the  vesical  portion  of  the  urethra,  slowly  dilating 
it  and  seeking,  if  possible,  the  band-like  sphincter  vesicse  (Fig.  293). 
Having  located  this  an  effort  is  made  first  to  separate  the  gland 
from  the  encircling  sphincter  by  entering  the  natural  line  of  cleavage 
which  exists  between  the  hyperplastic  glandular  masses  and  the 
muscular  fibers  (Fig.  294) . 

This  is  of  advantage  because,  if  the  internal  sphincter  is  preserved, 
the  patient  will  gain  control  of  his  urine  more  quickly  and  the 
control  will  be  more  perfect;  and  in  the  second  place,  where  this 
muscle  is  preserved,  one  seldom  has  any  troublesome  hemorrhage 


622 


PROSTATIC  OBSTRUCTIONS 


following  the  enucleation,  probably  because  a  rapid  contraction  of  the 
surrounding  tissues  takes  place.     In  the  case  of  fibrous  or  muscular 


FIG.  293. — Tip  of  index  finger  introduced  into  vesical  portion  of  the  urethra. 

hyperplasia  this  separation  of  the  sphincter  is  more  difficult.    In  every 
case  all  prostatic  tissue  should  be  cleared  from  the  sphincter  muscle. 


FIG.  294. — After  beginning  enucleation  of  the  urethral  aspect  of  the  lobe  the  finger 
follows  the  sphincter  muscles  around  the  prostatic  mass  until  the  prostate  is  entirely 
free  from  it.  If  this  is  done  before  the  prostate  is  removed,  the  sphincter  can  be  entirely 
freed  from  all  prostatic  tissue  and  there  will  consequently  be  less  bleeding. 

Having  accomplished  this,  the  finger  is  passed  farther  into  the 
urethra  until  the  most  distant  part  of  the  enlarged  gland  is  reached. 


ENLARGEMENT  OF  PROSTATE 


623 


Here  the  lines  of  cleavage  are  sought  and  the  enucleation  accomplished 
slowly,  gently  and  completely. 

The  work  of  enucleation  will  be  greatly  facilitated  if  the  operator 
introduces  one  or  two  fingers  into  the  rectum  to  lift  up  and  steady  the 
prostate  while  the  enucleation  is  being  accomplished. 

Details  of  the  Prostatic  Enucleation — With  the  finger  in  the  prostatic 
urethra,  the  point  of  least  resistance  in  the  mucous  membrane  of  the 
urethra  is  sought.  Usually  this  will  be  found  on  the  lateral  wall  of 
the  urethra.  At  this  point  the  division  between  the  prostate  and  the 
urethra  is  usually  quite  easily  broken  through.  The  finger  after  enter- 
ing the  line  of  cleavage  sweeps,  first,  slowly  around  the  distal  portion 


FIG.  295. — Prostate  elevated  by  finger  in  the  rectum;  index  finger  in  urethra 
enucleating  the  prostate. 

of  the  growth,  and  then  up  over  the  anterior  surface  of  the  growth, 
separating  it  from  the  prevesical  tissue.  The  finger  is  then  passed 
across  the  urethra  to  the  other  side  with  a  sweeping  motion  and  the 
opposite  lateral  lobe  is  freed  (Fig.  295).  The  finger  is  now  passed  over 
the  two  loosened  lateral  lobes,  then  beneath  and  between  them  and  the 
rectum,  and  then  the  finger  is  pulled  toward  the  bladder  so  that  the 
growth  will  be  pushed  into  the  bladder,  as  is  shown  more  clearly  in 
Fig.  296. 

The  point  which  is  most  difficult  to  free  is  that  which  is  most  distant 
from  the  bladder,  at  the  junction  of  the  prostatic  and  membranous 
urethra,  or  at  the  point  of  the  attachment  of  the  atrophied  middle 
lobe  distal  to  the  ejaculatory  ducts  which  part  of  that  lobe  probably 


624 


PROSTATIC  OBSTRUCTIONS 


is  not  removed  in  the  majority  of  cases.  Those  cases  in  which 
the  prostate  does  not  shell  out  easily  should  be  carefully  examined  for 
evidence  of  malignancy. 

A  peculiar  type  of  prostate  which  is  occasionally  encountered  is  that 
in  which  the  gland  is  enormously  hypertrophied  in  all  its  parts  except 
the  median  lobe.  In  removing  such  a  prostate  it  may  often  be  more 
easily  done  by  passing  the  finger  between  the  sphincter  vesicse  and  the 
growth  and  sweeping  the  finger  around  the  latter,  as  recommended  by 
Freyer.  It  will  quickly  fall  out  into  the  bladder.  However,  in  the 
majority  of  cases  the  intra-urethral  enucleation  is  to  be  preferred.  It 
is  quite  essential  for  the  welfare  of  the  patient  that  all  of  the  prostatic 


FIG.  296. — Enucleated  prostate  turned  out  into  the  bladder. 

tissue  as  far  as  possible  should  be  removed.  The  operator  should  not 
be  satisfied  with  removing  the  larger  adenomatous  mass  alone,  but  an 
attempt  should  be  made  to  bring  away  all  the  prostatic  tissue  unless 
there  is  a  diffuse  carcinomatous  involvement.  If  fragments  remain, 
they  retard  the  healing  of  the  cavity  from  which  the  prostate  has  been 
removed  and  are  apt  to  necrose  and  cause  a  delay  of  the  healing  process. 
Following  the  Enucleation. — Remove  all  foreign  material  from 
bladder,  i.  e.,  blood  clots,  the  enucleated  prostate,  loose  pieces  of  tissue, 
and  most  important  of  all,  any  small  prostatic  calculi  which  have  been 
forced  into  the  bladder  during  the  enucleation.  Frequently  these 
calculi  are  overlooked  and  they  may  remain  and  later  cause  distressing 
symptoms, 


ENLARGEMENT  OF  PROSTATE 


625 


A  small  gauze  sponge  is  the  best  instrument  with  which  to  remove 
such  calculi. 

The  Control  cf  Hemorrhage. — 1 .  By  removing  all  the  glandular  masses. 
This  allows  the  cavity  to  contract,  just  as  the  pregnant  uterus  does 
after  being  emptied. 

2.  By  direct  pressure,  one  finger  in  the  rectum  and  one  in  the  bladder, 
placing  all  torn  bits  of  attached  tissue  over  the  lacerated  area.     Fresh 
muscle  fibers  will  often  seal  the  opening  in  a  torn  vessel. 

3.  By  the  bag  hemostat.     We  no  longer  use  gauze  packing  to  control 
hemorrhage  in  these  cases,  because  of  the  large  amount  of  material 
necessary  to  secure  absolute  control  of  the  bleeding,  the  sloughing  of 


FIG.  297. — The  hemostatic  bag  of  Hagner. 

the  bladder  and  wound  which  may  follow  its  use,  the  pain  and 
unnecessary  disturbance  of  the  healing  surface  caused  by  its  removal. 
The  hemostat  of  Hagner3  provides  direct  pressure  on  the  bleeding 
surface  by  means  of  an  inflatable  rubber  bag  placed  within  the  bladder, 
the  degree  of  pressure  being  controlled  by  a  rubber  tube  which  passes 
down  through  the  urethra,  by  means  of  which  the  bag  is  inflated  and 
held  in  contact  with  the  lacerated  surface  (Fig.  297). 

The  writer  has  devised  a  hemostatic  bag  of  this  type  which  embodies 
some  new  features,  the  object  being  to  increase  the  comfort  and  to 
secure  the  safety  of  the  patient.  In  addition,  our  bag  provides  for 
the  drainage  of  the  urine  through  the  urethral  tube  (Figs.  298  and  299). 

To  place  the  bag,  a  well-curved  silver  catheter  is  passed  through  the 

M  y     i — 40 


626 


PROSTATIC  OBSTRUCTIONS 


urethra  into  the  bladder,  after  the  prostate  has  been  removed  until 
its  tip  projects  through  the  suprapubic  opening.  The  open  end 
of  the  urethral  tube  of  the  bag  is  threaded  over  the  end  of  the 


FIG.  298. — The  Pilcher  hemostatic  bag.  The  device  is  a  simple  inflatable  rubber  bag 
fashioned  about  a  large  size  catheter.  Cross-section  in  figure  below  shows  structure  of 
bag.  The  open  tube  catheter  is  entered  first  through  the  suprapubic  wound  over  a 
silver  catheter  and  drawn  down  through  the  urethra.  When  the  bag  is  in  the  bladder 
with  the  tube  in  the  urethra,  the  bag  is  inflated  through  the  inflating  tube  and  the 
inflated  bag  is  used  for  pressure  against  the  bleeding  surface  from  which  the  prostate 
was  removed.  When  pressure  is  desired  the  catheter  attachment  is  pulled  upon  which 
brings  the  bag  more  tightly  in  contact  with  the  bleeding  surface.  This  pressure  may  be 
maintained  by  attaching  the  catheter  tube  to  the  leg.  The  catheter  tube  also  acts  as  an 
avenue  for  the  escape  of  the  urine  from  the  bladder. 

silver  catheter  and  attached  there  by  means  of  a  silk  suture  passed 
through  the  eye  of  the  catheter.     The  silver  catheter  is  then  withdrawn, 


be  For  inflating  bag 


Operj-fube 


urethra 


FIG.  299. — Diagram  of  the  Pilcher  hemostatic  bag. 

bringing  with  it  the  rubber  tube  attached  to  the  bag.  This  tube 
is  then  secured,  the  bag  distended  with  air  through  the  other  tube 
provided  for  that  purpose,  and  with  one  finger  in  the  bladder,  the 


ENLARGEMENT  OF  PROSTATE 


627" 


urethral  tube  is  pulled  upon,  drawing  the  bag  down  into  the  area 
from  which  the  prostate  has  been  removed;  at  the  same  time  all  tags 
of  tissue  and  torn  muscle  fibers  are  tucked  in  front  of  the  bag  and  are 
brought  in  contact  with  the  lacerated  area  (Fig  300) .  The  urethral  tube 
is  attached  to  the  leg  by  means  of  adhesive  strips,  completely  controlling 
the  degree  of  pressure  desired  at  the  vesical  neck  (Fig.  301).  By 
this  means  we  have  a  safe  and  positive  means  of  controlling  hemorrhage 
which  can  be  removed  within  an  hour,  if  desired,  and  reapplied  at  will, 


Su1u 


FIG.  300. — Sketch  showing  complete  drainage  of  bladder 
with  hemostatic  bag  in  place  after  enucleation  of  the 
prostate,  inflating  tube  passing  up  through  or  beside 
large  drainage  tube.  In  two  or  three  hours  the  bag  is 
allowed  to  deflate  and  the  pressure  is  relaxed.  If 
bleeding  recommences,  the  bag  is  reinflated  and  pressure 
reestablished.  This  bag  is  removed  through  the  supra- 
pubic  wound  in  twenty-four  hours. 


FIG.  301.— Method  of 
attaching  catheter  tube 
attachment  of  hemostatic 
bag  to  the  leg  by  means 
of  adhesive  plaster  to  keep 
up  intra vesical  pressure 
on  the  lacerated  tissues. 
Note  test-tube  over  end 
of  catheter  to  receive  urine 
from  the  bladder. 


without  disturbing  the  patient.  Its  removal  at  the  same  time  that 
the  drainage  tube  is  changed  is  accomplished  with  relatively  little 
discomfort  to  the  patient. 

Drainage  of  the  Bladder.— This  we  consider  necessary  in  every  case 
of  transvesical  prostatectomy.  A  large  size  rubber  tube  is  used,  pre- 
ferably about  an  inch  in  diameter.  The  tube  extends  only  half  an  inch 
within  the  bladder  and  is  fastened  to  the  skin  by  a  silk  suture  (Fig.  302) . 
If  a  hemostat  bag  has  been  used,  the  air  tube  is  brought  out  through  the 


02S 


PROSTATIC  OBSTRUCTIONS 


drainage  tube  or  beside  it  (Fig.  303).  A  large  size  glass  connecting 
tube  is  attached  to  the  drainage  tube  and  a  second  rubber  tube  is 
attached  to  it,  whereby  the  secretions  from  the  bladder  are  collected  in 
a  bottle  at  the  bedside.  In  most  cases  this  will  be  most  satisfactory 
and  the  patient  will  be  kept  dry  for  the  first  twenty-four  hours  following 
the  enucleation. 

Management  of  the  Bag  Hemostat. — With  the  bag  inflated  and  in  posi- 
tion, we  have  an  absolute  control  of  the  hemorrhage.  The  amount 
of  tension  exerted  on  the  urethral  tube  controls  the  degree  of  pressure 
exerted  on  the  torn  periprostatic  tissues.  It  is  our  practice  to  exert  a 
considerable  amount  of  pressure  for  the  first  hour  after  prostatectomy. 
At  the  end  of  an  hour  all  bleeding  will  have  stopped.  The  adhesive 
strips  attaching  the  urethral  tube  to  the  leg  are  divided,  the  bag  is 
deflated  and  it  remains  in  place  but  exerts  no  pressure.  The  urethral 


FIGS.  302  and  303. — Surface  view  of  drain  and  dressing  following  suprapubic  cystos- 
tomy  in  which  bag  hemostat  has  been  used,  the  smaller  tube  being  the  inflating  tube  of 
the  hemostatic  bag. 

tube  in  the  meantime  is  functionating  as  a  catheter  and  is  draining 
the  urine  from  the  bladder  into  a  bottle.  In  other  words,  we  have 
provided  a  double  exit  for  the  urine,  and  the  result  is  added  comfort  to 
the  patient,  a  dry  clean  wound,  and  a  great  reduction  in  the  dressings. 
If  any  bleeding  should  start  again  it  is  a  simple  matter  to  dilate  the  bag 
with  air  and  reapply  the  pressure.  The  bag  is  removed  in  from 
twenty-four  to  forty-eight  hours. 

First  Twenty-four  Hours  after  Operation. — If  the  patient  is  comfort- 
able and  dry  and  the  draining  tube  is  not  causing  pain  or  spasm  of  the 
bladder,  he  is  not  disturbed  in  any  way.  If  desired,  he  is  allowed  to  sit 
up  in  a  chair  the  day  following  operation. 

If  the  bag  hemostat  is  causing  trouble  it  may  be  removed  together 
with  the  suprapubic  drainage  tube  at  the  end  of  twenty-four  hours, 
otherwise  it  is  left  in  place  for  forty-eight  hours. 


ENLARGEMENT  OF  PROSTATE  629 

Forty-eight  Hours  after  Operation. — It  is  our  custom  to  remove  the 
bag  hemostat  and  drainage  tube  at  the  end  of  forty-eight  hours. 
This  is  easily  accomplished.  The  distal  end  of  the  urethral  tube  is 
cleansed  and  covered  with  vaselin.  The  suture  holding  the  drainage 
tube  is  cut,  and  the  tube  and  bag  are  slowly  and  gently  withdrawn  from 
the  suprapubic  wound.  A  long,  narrow  retractor  is  immediately  placed 
in  the  drainage  tract  to  guide  us  in  introducing  the  button  drainage 
tube.  Depending  upon  the  character  of  the  wound  we  choose  a  specially 
made  de  Pezzer  or  Pilcher  catheter,  or  a  button  tube.  Grasping  the 
enlarged  end  of  the  tube  with  a  pair  of  dressing  forceps  it  is  passed 
along  the  groove  of  the  narrow  retractor  until  the  end  enters  the 
bladder.  Then  the  forceps  and  retractor  are  withdrawn,  leaving  the 
button  end  of  the  tube  in  the  bladder.  In  most  cases  the  bladder 
wall  will  immediately  contract  and  hold  the  tube  in  place.  In  some 
cases  this  will  take  three  or  four  hours.  When  the  tube  is  in  place 
it  is  carefully  tested  by  a  small  amount  of  irrigation  to  make  sure 
that  it  drains  the  bladder.  Frequently  some  of  the  irrigating  fluid 
returns  around  the  tube,  but  in  practically  every  case  the  greater 
part  returns  through  the  tube,  if  it  is  properly  placed.  When  satisfied 
that  the  tube  is  in  proper  position  it  is  fastened  by  an  adhesive  strip 
(Fig.  290),  and  attached  to  an  extension  tube  which  is  lead  to  the 
bottle.  In  most  cases  this  tube,  if  correctly  placed,  will  drain  all  of 
the  urine  from  the  bladder,  and  after  a  period  of  a  few  hours  will  keep 
the  patient  perfectly  dry.  This  we  consider  a  great  advantage  to  the 
patient. 

At  the  end  of  twenty-four  hours,  some  patients,  and  after  forty-eight 
hours,  most  of  them  are  allowed  to  get  out  of  bed.  Common  sense 
and  not  rule  governs  this  phase  of  the  subject. 

Control  of  the  Bladder.  —  One  Week  after  Operation. — By  this  time 
the  healing  at  the  neck  of  the  bladder  is  well  advanced,  and  it  is 
time  to  think  of  using  the  urethra  again.  (In  one  of  our  cases 
the  suprapubic  wound  healed  in  four  days.)  At  the  end  of  a  week 
the  button  drainage  tube  is  still  in  place,  and  in  most  cases  the 
patient  is  dry.  In  some  cases  there  will  still  be  leakage  beside  the 
tube.  When  the  patient  is  dry  we  encourage  the  use  of  the  urethra. 
We  temporarily  close  the  drainage  tube  and  allow  the  bladder  to 
partially  fill.  Then  the  patient  is  told  to  try  and  void  per  urethram. 
It  is  surprising  to  note  how  many  will  succeed.  The  majority  begin  by 
passing  a  dram  or  two  each  time,  every  hour  a  little.  At  the  end  of 
twenty-four  hours  the  patient  will  be  passing  an  ounce  or  so  every 
hour  and  gradually  he  resumes  his  natural  habit.  All  of  this  time  we 
have  the  drainage  tube  as  a  safety  valve.  In  a  few  days  we  find  that 
most  patients  no  longer  need  the  tube,  and  it  is  removed.  Some 
suprapubic  leakage  will  occur  for  a  day  or  so,  but  in  many  cases  there 
will  be  very  little  after  twenty-four  hours.  This  depends,  however,  to  a 
considerable  extent  on  the  care  and  exactness  with  which  the  first  stage 
of  the  operation  has  been  carried  out.  This  refers  especially  to  the 
placing  of  the  opening  in  the  bladder  and  the  healing  of  the  wound. 


630 


PROSTATIC  OBSTRUCTIONS 


The  suprapubic  opening  heals  rapidly  and,  as  a  rule,  is  entirely  free  from 
the  necrotic,  phosphate  encrusted  tissues. 

The  technic  above  described  is  applicable  in  the  majority  of  cases  of 
prostatic  hypertrophy,  and  \vhen  followed  will  give  the  patient  the 
maximum  of  security  with  the  minimum  amount  of  suffering. 

The  various  steps  of  the  scheme  can  be  best  seen  in  review  by  referring 
to  the  chart. 


TABLE  SHOWING  DETAIL  OF  IMPORTANT  PHASES  IN  A  TWO-STAGE  THANSVESICAL 
PROSTATECTOMY.     TECHNIC  EMPLOYED  BY  THE  WRITER. 


Restoration  of  Renal  Function.        Drainage  of  Bladder. 

Preferably  by  means  of  a  All  urine  collected  through 
suprapubic  cystostomy,  tube;  no  urinary  leakage 
using  button  drainage  tube  around  tube :  patient  dry  • 
(Fig.282) ;  local  anesthesia.  out  of  bed  OP  second  day. 


First  Twenty-four  Hours 

after  Operation. 
Patient    dry;    urine    drains 
through  suprapubic  tube 
and  urethra!  tube  if  em- 
ployed. 


Second  or  Third  Day. 
Primary  suprapubic  tube 
out  and  replaced  by  but- 
ton drainage  tube;  hemo- 
stat  bag  removed :  patient 
wet  for  two  to  three  hours. 

CONTBOL  or  BLADDER. 


Second  Operation. 
Transvesical  finger  enuclea- 
tion    of    prostate;    ether 
anesthesia     five    to    ten 
minutes. 


Third  to  Seventh  Day. 
All    urine    coming    through 
button     drainage     tube: 
patient  dry;  out  of  bed. 


Seventh  Day. 
Control  of  bladder 
begun;  with  drain- 
age tube  temporar- 
ily closed  during 
day,  urination  per 
urethram  is  begun; 
every  hour  at  first: 
patient  dry. 


Eighth  to  Tenth  Day. 

Control  of  bladder 
continued ;  gradual 
lengthening  of  in- 
terval between  uri- 
nation to  three 
hours:  patient  dry. 


Eleventh  Day. 
Wound  well  cicatrized : 
button  drainage 
tube  removed:  uri- 
nation continues; 
slight  urinary  leak- 
age. 


Thirteenth  to 

Twentieth  Day. 

Sinus  healed. 


Control  of  Hemorrhage. — In  addition  to  the  methods  already  described 
for  controlling  hemorrhage  the  following  means  have  been  employed. 

Fenwick  Method  by  Clamp  and  Ligature. — Fenwick  has  devised  a 
series  of  three  specula  of  different  sizes  which  may  be  introduced 
through  the  suprapubic  wound,  bringing  the  area  from  which  the  pros- 
tate has  been  removed  directly  into  view.  The  use  of  one  of  these 
specula  is  illustrated  in  Fig.  304.  The  headlight  is  used  to  illuminate 
the  cavity.  With  the  lacerated  oozing  area  in  view  and  properly  illumi- 
nated, the  area  is  sponged  as  dry  as  possible  and  it  will  be  found,  as  a 
rule,  that  bleeding  does  not  come  so  much  from  the  cavity  from  which 
the  prostate  has  been  removed,  but  usually  from  the  free  edges  of  the 
lacerated  tissue  which  covers  the  surface  of  the  prostate  on  its  vesical 
aspect.  The  area  from  which  the  prostate  has  been  removed  flattens 
out  very  quickly  and  does  not  remain  as  a  cavity,  but  contracts  and, 
usually,  does  not  allow  space  for  the  accumulation  of  blood  clots. 
Through  the  speculum  the  bleeding  points  are  caught  with  specially 
devised  hemostats.  In  this  way  the  bleeding  can  be  entirely  con- 
trolled. In  most  cases  after  a  few  minutes'  crushing  with  the  hemo- 


ENLARGEMENT  OF  PROSTATE 


631 


stats  they  may  be  removed  and  no  further  bleeding  will  occur.  The 
hemostats  are  so  constructed  that  the  handles  may  be  removed,  if 
necessary,  and  the  instruments  may  be  left  in  situ  for  twenty-four  hours. 

As  a  modification  of  this  method  the  writer  would  suggest  the  use  of 
the  actual  cautery  through  the  speculum  to  control  any  bleeding-point 
which  might  come  into  view. 

Control  by  Suture. — A  number  of  prominent  operators  complete  their 
prostatectomies  by  surrounding  the  area  from  which  the  prostate  has 
been  removed  by  a  continuous  or  by  interrupted  catgut  sutures.  This 
necessitates  a  large  suprapubic  wound  and  consumes  considerable  time 
and,  in  the  experience  of  the  writer,  has  never  been  found  necessary. 


FIG.  304. — The  Fenwick  bladder  speculum  in  place. 

Control  by  Pressure. — With  one  ringer  in  the  rectum  and  a  finger  in 
the  bladder  the  tissues  involved  in  the  prostatic  wound  may  be  pressed 
together  and  in  this  way  much  oozing  will  be  prevented.  At  the 
meeting  of  the  American  Urological  Society  in  Boston,  April,  1913,  the 
writer  presented  a  method  of  controlling  hemorrhage,  using  gauze 
packing.  This  consists  of  introducing  a  catheter  through  the  urethra 
which  serves  as  a  staff  around  which  the  packing  is  to  be  placed. 
Then  a  narrow  strip  of  gauze  is  introduced  through  the  suprapubic 
wound  and  the  torn  edges  of  mucous  membrane  which  have  been 
stripped  up  from  the  prostate  are  pressed  down  into  the  shallow 
prostatic  pouch  and  held  in  place  by  gauze  packing,  as  is  shown  in 
Fig.  305.  This  shows  the  prostatic  pouch  exaggerated,  with  the  torn 


632 


PROSTATIC  OBSTRUCTIONS 


flaps  of  mucous  membrane  pushed  before  the  gauze  packing  and  in 
addition  a  de  Pezzer  catheter  used  to  hold  the  gauze  packing  in  place. 
This  de  Pezzer  catheter  may  be  introduced  by  first  passing  a  silver 
catheter  through  the  urethra  and  out  through  the  suprapubic  wound, 
then  attaching  the  small  end  of  the  de  Pezzer  catheter  to  the  silver 
catheter  and  drawing  it  out  through  the  urethra.  With  the  expanded 
end  of  the  catheter  on  the  vesical  side  of  the  packing  considerable  press- 
ure may  be  brought  to  bear,  using  a  very  small  amount  of  gauze  packing 
by  pulling  on  the  outer  end  of  the  catheter.  Up  to  the  present  time 
we  have  always  used  the  simple  rubber  catheter  as  a  staff  around 


FIG.  305. — Bed  of  prostate  packed  with  gauze  around  catheter  a  demeure. 

which  to  pack  the  gauze.  The  end  of  the  gauze  is  led  out  through  the 
abdominal  wound.  The  bag  hemostat,  however,  has  been  found  to  be 
the  best  method  of  controlling  the  bleeding. 

Control  of  Secondary  Hemorrhage  from  the  Bladder. — Hemorrhages 
occurring  within  twelve  to  twenty-four  hours  after  the  prostatectomy 
are  best  controlled  by  packing  the  prostatic  pouch  around  a  catheter 
introduced  through  the  urethra.  In  one  case  the  writer  passed  a  silk 
suture  through  the  perineum,  placed  a  gauze  packing  over  the  pros- 
tatic pouch  and  fastened  the  silk  suture  to  this  gauze  packing,  tying  the 
same  on  the  outside  of  the  perineum.  Secondary  hemorrhage  which 
occurs  a  week  or  so  after  the  operation  may  be  either  from  the  wound 
itself  which  calls  for  its  reopening  and  suture,  or  it  may  be  from  the 


633 


vesical  neck  or  the  prostatic  pouch  itself.  Such  an  occurrence  calls  for 
reopening  of  the  bladder,  exposure  of  the  bleeding-point  and  securing 
it  either  by  suture  or  touching  it  with  the  actual  cautery  or  the 
high-frequency  spark  generated  from  the  D'Arsonval  current.  In  one 
case  of  my  own  it  was  necessary  after  the  second  week  to  reopen  the 
bladder  widely  and  cauterize  the  entire  area  of  the  vesical  neck  before 
the  hemorrhage  could  be  stopped. 

Variations  in  Technic. —  The  Trocar  and  Cannula  for  Suprapubic 
Drainage  of  the  Bladder. — This  technic  has  been  recently  worked  out 
by  Lower,5  of  Cleveland.  He  describes  it  as  follows: 

Using  a  local  anesthetic,  or  without  any  anesthetic  even,  the  trocar 
and  cannula  may  be  forced  into  the  bladder  at  a  point  sufficiently 
distant  from  the  pubis  to  avoid  puncturing  the  plexus  of  veins  which 
lies  just  behind  the  pubic  bone.  The  trocar  is  then  withdrawn,  and  a 
sterile  No.  14  soft-rubber  catheter  is  inserted  through  the  cannula  into 
the  bladder.  The  cannula  is  withdrawn  and  the  bladder  emptied 


FIG.  306. — Trocar  and  cannula  with  metal  collar.     (Lower.) 

through  the  catheter,  which  is  allowed  to  remain.  The  retained 
catheter  can  be  held  in  place  by  adhesive  plaster,  the  end  being  plugged 
or  compressed  until  relief  is  again  needed.  The  catheter  may  remain 
in  place  for  days,  if  necessary,  without  doing  any  harm  and  in  the 
meantime  the  patient  can  be  made  ready  for  operation  or  further 
treatment.  It  may  happen  that  after  several  days  of  suprapubic 
drainage  the  patient  will  again  be  able  to  void  urine.  This  method 
often  is  a  more  comfortable  way  of  securing  continuous  drainage  of  the 
bladder  as  a  preparation  for  prostatectomy  than  is  the  insertion  of  a 
catheter  through  the  urethra,  as  the  latter  method  is  generally  irritat- 
ing and  disturbs  the  patient  greatly. 

If  no  soft  catheter  of  the  proper  size  is  available  the  cannula  itself 
may  be  retained,  if  it  is  fastened  with  tape  inserted  through  the 
small  slits  in  the  collar.  The  writer  has  never  seen  a  permanent 
fistula  follow  the  use  of  the  trocar. 

This  method  is  not  recommended  to  replace  the  preliminary  cystos- 


FIG.  307. — Introduction  of  trocar.     (Lower.) 


FIG.  308. — Introduction  of  catheter  through  cannula.      (Lower.) 


FIG.  309. — Cannula  withdrawn.     Catheter  remaining.      (Lower.) 


FIG.  310. — Cannula  fastened  in  and  secured  by  tapes  through  small  openings  in  the 
metal  collar.     (Lower.) 


636 


PROSTATIC  OBSTRUCTIONS 


tomy,  for  two  reasons:  First,  the  opening  in  the  bladder  is  too  low 
down;  and  second,  because  the  opening  is  not  large  enough  to  permit 
removal  of  the  prostatic  growth. 

The  bladder  should  be  full  when  the  trocar  is  inserted  into  it. 

Transvesical  Prostatectomy  by  the  Open  Method. — Many  operators 
still  prefer  to  complete  the  operation  of  transvesical  prostatectomy  hi 


FIG.  311. — Cavity  left  after  removal  of    prostate  and  bladder  caught  preparatory  to 

suturing.     (Judd.) 


one  stage,  always,  however,  preceded  by  a  period  of  preliminary  treat- 
ment of  intermittent  catheterism  or  permanent  bladder  drainage 
through  the  urethra.  Our  objections  to  this  have  already  been  noted. 
There  are  those  also  who  prefer  the  open  method  of  prostatectomy 
even  after  preliminary  suprapubic  drainage,  either  by  the  method  of 
cystostomy,  or  the  introduction  of  a  suprapubic  tube  through  a  trocar 
opening. 


ENLARGEMENT  OF  PROSTATE 


637 


Either  through  a  primary  incision  or  by  enlarging  the  opening  which 
already  exists,  the  interior  of  the  bladder  is  exposed.  The  bladder  wall 
is  cut  sufficiently  to  give  a  good  exposure  of  the  vesical  neck,  care 
being  exercised  not  to  carry  the  incision  too  near  the  urethral  opening. 
Suitable  retractors  are  introduced.  Then  using  a  large  syringe,  a 
solution  of  novocain  0.25  per-  cent,  containing  a  small  amount  of 
adrenalin  is  injected  into  the  prostate  especially  at  its  periphery.  This 


FIG.  312. — a,  prostatic  capsule  partially  closed  by  interrupted  suture;  b,  sutures  in 
place  investing  mucous  coat.     (Judd.) 

tends  to  block  the  nerves  and  the  enucleation  may  then  be  done  in  a 
number  of  different  ways.  Some  operators  prefer  to  incise  the  mucous 
membrane  over  the  more  prominent  portions  of  the  gland  and  the 
separation  of  the  mass  is  started  with  a  blunt  dissector  or  the 
gloved  finger.  The  technic  of  Dr.  Judd,  of  Rochester,  Minn.,  is  most 
excellent.  He  grasps  the  prostatic  mass  with  forceps,  when  possible, 
and  lifts  it  up,  at  the  same  time  using  one  or  two  fingers  to  free  it  from 
the  bladder  wall  and  sphincter  muscle.  From  here  on  the  method  of 


638  PROSTATIC  OBSTRUCTIONS 

enucleation  is  practically  the  same  in  all  cases,  the  prostate  being 
shelled  out  by  forcing  the  finger  between  and  around  the  enlarged  lobes 
and  turning  them  out  into  the  bladder.  After  the  mass  has  been 
removed  from  the  bladder,  the  lacerated  area  is  inspected  and  if  any 


' 


FIG.  313. — a,  self-retaining  retractors  removed  and  roof  of  bladder  ready  for  closure; 
b,  bladder  closed  with  continuous  suture  of  chromic  catgut,  avoiding  mucous  coat 
(Judd.) 

spurting  vessels  are  seen,  these  are  secured  and  tied  with  catgut  (Fig. 
311).  As  a  routine,  Judd  places  a  few  sutures  of  chromic  gut  through 
the  bladder  wall,  including  the  depths  of  lacerated  tissue  on  either  side 
of  the  lacerated  posterior  urethra,  and  ties  them,  thus  controlling  the 
oozing  surfaces  and  the  cut  edges  of  the  bladder  mucous  membrane 


ENLARGEMENT  OF  PROSTATE 


639 


(Figs.  311  and  312).  Most  operators  prefer  to  close  the  suprapubic 
wound  around  a  drain  of  large  calibre  to  prevent  the  accumulation 
of  blood  clots.  In  selected  cases  where  the  hemorrhage  seems  to  be 
controlled,  Judd  prefers  to  insert  a  catheter  through  the  urethra  and 
close  the  suprapubic  wound  entirely.  In  his  hands  this  method  seems 
safe,  but  as  yet  the  writer  feels  that  it  cannot  be  recommended  for 
general  use.  The  after-care  is  the  same  as  in  the  two-stage  operation. 


FIG.  314. — Perineal  prostatectomy,  primary  incision. 

Technic  of  Perineal  Prostatectomy. — Before  the  Incision — The  patient 
is  placed  on  a  firm  table  in  an  exaggerated  lithotomy  position,  the 
pelvis  elevated  by  sand-bags  or  other  special  supports  to  a  degree 
that  will  bring  the  plane  of  the  perineum  as  nearly  horizontal  as  pos- 
sible. The  rectum  should  have  been  emptied  by  an  enema  administered 
at  least  eight  hours  before  the  hour  of  operation.  The  scrotum,  peri- 
neum, and  adjacent  thigh  surfaces  having  previously  been  shaved  and 
cleaned,  should  again  be  scrubbed  and  disinfected  after  the  patient  has 
been  placed  in  position.  A  full-sized  sound,  No.  26  to  30  (French), 
should  be  introduced  through  the  urethra  into  the  bladder  and  held 
by  an  assistant.  Should  strictures  in  the  anterior  urethra  be  detected, 


640 


PROSTATIC  OBSTRUCTIONS 


they  should  be  freely  divided  by  a  urethrotome  at  this  time.  The  sound 
in  the  urethra  should  not  be  made  to  project  into  the  perineum,  but 
should  be  raised  so  as  to  bring  the  membranous  urethra  as  close  as 
possible  to  the  pubic  arch  and  increase  the  distance  between  the  urethra 
and  the  rectum  (Proust) . 

The  Primary  Incision. — A  curved  incision  through  skin  and  superficial 
fascia  is  then  made,  distant  an  inch  to  an  inch  and  a  half  in  front  of  the 
anus  and  extending  from  ischium  to  ischium  (Fig.  314). 

The  Exposure  of  the  Recto-urethral  Muscle. — This  is  a  step  of  the 
highest  importance,  since  this  semi-aponeurotic  muscle  is  the  only  real 
barrier  in  the  way  of  free  access  to  the  periprostatic  space.  By  its 


FIG.  315. — The  bulb  of  the  urethra  exposed. 

prolongation  anteriorly  the  membranous  urethra  is  swung  from  the 
pubic  arch  and  its  main  portion,  inserted  into  the  anterior  wall  of  the 
rectum  above  the  internal  sphincter,  draws  that  portion  of  the  rectum 
forward  toward  the  urethra ;  in  many  instances  in  the  aged  the  bulb  is 
so  enlarged  (Fig.  315)  that  its  backward  projection  is  sufficient  to  cover 
entirely  the  space  between  rectum  and  urethra.  The  delimitation  of 
the  bulb  is  quickly  accomplished  after  the  division  of  the  anobulbar 
raphe.  The  bulb  is  then  drawn  forward  in  the  grasp  of  a  forceps  until 
the  membranous  urethra  is  identified,  distended  as  it  is  by  the  sound 
that  fills  it,  but  obscured  by  the  recto-urethralis  muscle.  As  the  bulb 
is  drawn  forward  the  posterior  edge  of  the  transverse  perineal  muscle 


ENLARGEMENT  OF  PROSTATE  641 

on  each  side  is  made  tense  and  identifiable,  and  is  a  guide  to  the  location 
of  the  artery  of  the  bulb  which  is  to  be  avoided.  Just  behind  these 
transverse  fibers  and  vessels  to  the  outer  side  of  the  urethra  is  a  weak 
spot  in  the  deep  perineal  fascia  through  which  the  tip  of  the  finger  can 
readily  be  made  to  bore,  and  to  penetrate  alongside  the  membranous 
urethra  as  far  back  as  the  prostate.  The  finger-tip  thrust  in  at  this 
point  pressing  outward  and  backward  toward  the  ischia  quickly  opens 
up  these  lateral  spaces,  into  which  suitable  retractors  are  placed. 

The  Exposure  of  Prostate. — The  detachment  of  the  recto-urethra! 
fibers  from  the  face  of  the  membranous  urethra  is  now  readily 
effected,  guided  by  the  eye  and  aided  by  the  scissors  or  the 
knife,  but  for  the  most  part  bluntly  done  by  the  finger.  The  rectum, 
now  freed  from  its  anterior  attachments,  is  pushed  backward;  the 
connective  tissue  about  the  urethra  and  the  face  of  the  prostate  is 
readily  detached  and  rolled  back  by  the  finger-tips  until  the  rectopros- 
tatic  space  is  penetrated  as  deeply  as  the  conditions  may  require.  A 
broad,  blunt-edged  retractor  is  adjusted  so  as  to  keep  the  rectum  drawn 
back  from  the  field  and,  with  the  assistance  of  the  lateral  retractors 
already  placed,  the  prostate  is  fully  exposed.  The  description  of  the 
operative  steps  thus  far  may  have  seemed  long,  but  the  work  itself 
advances  steadily  from  point  to  point,  and  does  not  take  much  time 
for  its  accomplishment.  (In  the  experience  of  the  writer  from  ten  to 
twelve  minutes.) 

The  Downward  Traction  of  the  Prostate. — The  prostate  may  be 
forced  down  toward  the  perineal  surface  by  strong  pressure  from 
above  the  pubis,  or  it  may  be  seized  by  suitable  traction  forceps 
introduced  through  the  perineal  wound  and  dragged  down  so  as  to 
be  more  accessible  to  attack;  but  it  is  better  done  by  tractors 
which  are  introduced  through  the  membranous  urethra  into  the 
bladder  and  by  opening  their  intravesical  blades  whereby  strong 
traction  can  be  exercised  upon  the  base  of  the  bladder.  Such  are 
the  tractors  of  Lydston,  Syms,  de  Pezzer  and  Young  (Figs.  316, 
317,  318  and  319).  Of  these  we  have  used  with  great  satisfaction  the 
model  devised  by  Young.  The  time  for  its  introduction  is  after  the 
prostate  has  been  fully  exposed,  as  described  in  the  preceding  paragraph . 
The  membranous  urethra  is  also  fully  exposed  in  the  wound  distended 
.  by  the  sound,  which  now  serves  as  a  guide  by  which  to  incise  the  pros- 
tatic  urethra,  beginning  at  the  apex  of  the  gland  and  extending  the 
incision  as  far  backward  as  may  be  necessary  to  give  room  for  the  ready 
introduction  of  the  rather  blunt  and  clumsy  beak  of  the  tractor.  After 
the  incision  has  been  made  the  sound  is  withdrawn,  the  edges  of  the 
incision  are  held  apart  by  tenacula  or  loops  of  thread  that  have  been 
inserted  into  them,  and  the  tractor  passed  through  the  prostatic  urethra 
into  the  bladder.  Its  blades  are  then  rotated  so  as  to  form  two  diver- 
gent wings  within  the  bladder,  by  means  of  which  traction  is  made 
with  a  minimum  of  injury  to  the  mucous  membrane  of  the  bladder. 
Such  an  instrument  is  more  than  a  tractor;  it  is  practically  an 
elongated  finger  by  means  of  which  the  operator  can  appreciate  to  a 

MU      I 41 


642 


PROSTATIC  OBSTRUCTIONS 


FIG.  316. — Young's  prostatie  tractor  (open). 


FIG.  317. — Young's  prostatie  tractor  (closed). 


FIG.  318. — de  Pezzer's  tractor  (open). 


FIG.  319. — de  Pezzer's  tractor  (closed). 


ENLARGEMENT  OF  PROSTATE  643 

notable  degree  the  conditions  within  the  bladder,  can  make  such 
graduated  pressure  as  he  may  require  to  facilitate  the  progress  of  the 
enucleation,  and  can  gauge  the  extent  of  his  work  at  any' time.  It 
contributes  to  a  notable  degree  to  the  positiveness  and  accuracy  of 
the  work. 

Enucleation  of  the  Gland  (Figs.  324,  325,  326,  and  327).— To  effect 
this  the  technic  described  by  Young  will  be  found  to  be  very  satisfactory. 
The  prostate  having  been  brought  forward  and  exposed,  two  free  longi- 
tudinal incisions  are  made  through  the  capsule  to  a  depth  of  about  one 
and  a  half  centimeters  into  the  substance  of  the  gland  (Fig.  320),  one 
on  either  side  of  the  urethra.  These  are  about  one  and  a  half  centi- 
meters apart  in  front  and  diverge  slightly  as  they  pass  backward.  The 


FIG.  320. — The  enucleation  of  the  prostate. 

bridge  of  tissue  that  lies  between  them  supports  the  urethra  and  con- 
tains the  ejaculatory  ducts.  The  outer  edge  of  one  of  the  wounds  in 
the  capsule  is  then  seized  with  forceps  to  steady  i't,  and  a  blunt 
dissector  entered  in  the  line  of  cleavage  that  presents;  with  this 
the  lateral  lobe  is  readily  enucleated  anteriorly  and  externally; 
the  partially  turned-out  mass  can  be  seized  with  suitable  traction 
forceps  and  pulled  upon  to  facilitate  the  separation  of  the  deeper 
portion.  The  finger-tip  may  now  be  substituted  for  the  blunt  dissector 
as  the  enucleation  extends  into  a  region  beyond  the  control  of  the  eye. 
As  that  portion  of  the  mass  is  reached  which  ( lies  adjacent  to  the 
urethra  it  should  be  separated  with  especial  care  to  avoid  tearing  the 
urethra;  the  blunt  dissector,  the  touch  of  the  knife  point,  or  a  snip  of 
the  scissors  may  be  required  to  divide  the  bands  of  tissue  that  unite 


644  PROSTATIC  OBSTRUCTIONS 

it  to  the  urethral  wall.  The  other  lateral  mass  is  then  removed  in  the 
same  manner.  The  presence  of  a  median  lobe  is  then  readily  determined 
by  the  combined  manipulation  of  the  finger-tip  in  the  lateral  pros- 
tatic  cavities  and  the  tractor  in  the  bladder,  and  if  present  may  be 
brought  down  within  reach  of  the  enucleating  finger  with  marked  ease 
by  the  pressure  of  the  suitably  placed  intravesical  blades  of  the  tractor, 
freed  and  turned  out  through  one  of  these  lateral  spaces  without 
injury  to  the  bladder,  and  in  many  cases,  it  is  believed,  without  injury 
to  the  ejaculatory  ducts.  If  palpation  reveals  now  the  further  presence 
of  a  mass  in  the  posterior  median  bridge  still  left,  it  can  be  exposed 
by  transverse  incision  and  enucleated,  but  such  removal  would  entail 
cutting  across  the  ejaculatory  ducts.  In  the  relatively  small,  hard, 
fibrous  prostates  the  enucleation  of  the  small  glandular  nodules  may 
be  readily  accomplished,  but  for  the  removal  of  the  greater  part  of  each 
lobe  there  is  required  piecemeal  excision  by  traction  forceps  and  scissors. 

The  operator  will  be  able  to  determine  with  great  facility  and 
accuracy  the  thickness  of  the  tissue  intervening  between  the  depth  of 
his  dissection  and  the  cavity  of  the  bladder  by  the  tip  of  his  finger  in  the 
wound  pressed  against  the  broad  blades  of  the  tractor  in  the  bladder. 
By  the  tractor  also,  used  as  a  searcher,  for  which  its  shape  well  fits  it, 
the  presence  of  calculi  in  the  bladder  will  be  determined.  If  a  calculus 
is  present  it  is  to  be  removed  through  the  prostatic  urethra  by  the 
appropriate  instruments  required  for  the  purpose. 

In  cases  of  fibrous  contracture  of  the  internal  meatus  an  incision  of 
the  floor  of  the  prostatic  urethra  through  the  ring  into  the  bladder 
should  be  made. 

If  a  pedunculated  median  intravesical  growth  is  found  that  cannot 
readily  be  everted  into  a  lateral  cavity,  the  prostatic  urethra  should  be 
incised  backward  sufficiently  to  allow  of  the  tumor  being  caught  and 
brought  out  into  the  urethral  wound  and  cut  away. 

The  Primary  Wound  Dressing. — The  tractor  having  been  with- 
drawn after  the  blades  have  been  closed,  all  clots  are  cleared  from 
the  bladder  by  irrigation.  Then  a  permanent  catheter  preferably 
of  large  size  of  soft  rubber  is  tied  into  the  bladder  through  the 
entire  length  of  the  urethra.  This  is  to  remain  for  a  week.  The 
peri-urethral  tissues  are  sutured  around  this  catheter,  using  several 
sutures  of  chromic  catgut.  The  deep  urethral  spaces  of  the  wound  are 
brought  together  by  sutures  of  chromic  gut  around  a  small  tampon  of 
silver  nitrate  gauze  and  a  short  rubber  drainage  tube  which  extends 
to  the  deepest  part  of  the  wound  cavity.  The  tampon  and  the  tube 
are  removed  on  the  third  to  the  fifth  day,  at  which  time  the  cavity  is 
irrigated.  The  urethral  catheter  is  removed  on  the  seventh  day.  The 
superficial  parts  of  the  wound  are  sutured  with  silkworm  gut  around 
the  drainage.  The  results  following  this  method  of  after-treatment 
have  been  highly  satisfactory.  The  perineal  wounds  have  rapidly  closed ; 
permanent  fistulse  are  of  very  rare  occurrence ;  the  ability  of  the  bladder 
to  retain  and  expel  its  contents  at  due  intervals  is  early  regained,  with 
the  reservation  as  to  some  instances  of  temporary  defects  in  reten- 


ENLARGEMENT  OF  PROSTATE 


645 


tion;  and  no  strictures  of  the  urethra  have  developed  in  the  writer's 
experience.  In  some  cases  we  simply  place  a  large  rubber  drain  tube 
through  the  opening  in  the  prostatic  urethra  into  the  bladder  and  secure 
its  outer  end  at  one  angle  of  the  external  perineal  wound  (Fig.  321)  by 
a  point  of  suture,  at  the  same  time  laying  a  gauze  tampon  in  the  depth 
of  the  perineal  wound.  The  tampon  is  removed  on  the  fifth  day,  the 
bladder  drained  on  the  seventh  day,  when,  after  an  irrigation  of  the 
bladder  and  urethra,  a  sound  is  passed  through  the  urethra  into 
the  bladder.  The  later  history  of  these  cases  has  been  quite  as  favor- 
able as  those  in  which  the  preceding  method  of  operation  was  em- 
ployed, and,  as  the  method  is  more  simple  and  less  irksome  to  the 
patient,  we  are  inclined  to  regard  it  as  to  be  preferred,  unless  further 
experience  should  show  it  to  be  attended  with  greater  liability  to  the 
development  of  distortions  or  strictures  of  the  urethra. 


FIG.  321. — The  perineal  wound  closed. 


After-treatment. — Local. — The  local  cares  are  very  simple,  relating 
merely  to  those  of  any  drained  wound,  plus  the  provisions  for  carry- 
ing away  the  urine.  To  the  retained  catheter  is  attached  a  sufficient 
length  of  rubber  tubing  to  reach  a  bottle  hung  at  the  side  of  the  bed, 
which  receives  the  urine  conveyed  through  the  tube.  An  absorbent 
compress  to  the  perineal  wound,  retained  by  a  T-bandage,  constitutes 
the  dressing.  The  removal  of  the  gauze  tampon  on  the  fifth  day,  and 
of  the  drain  or  catheter  on  the  seventh  day,  and  the  opening  of  the 
urethra  by  sound,  have  already  been  discussed.  Instrumentation 
applied  to  the  urethra  or  the  wound  cavity  should  be  avoided  as  far 
as  possible;  but  such  a  minimum  use  of  the  sound  as  may  be  required  to 


646  PROSTATIC  OBSTRUCTION 

assure  the  surgeon  of  the  continuity  and  full  patency  of  the  urethral 
canal  should  not  be  omitted. 

The  treatment  of  a  complicating  cystitis  should  receive  such  attention 
as  the  condition  of  the  particular  patient  may  determine.  Continuous 
irrigation  of  the  bladder  after  operation  is  seldom  indicated. 

General  Considerations. — The  aged  men  who  are  subjected  to  perineal 
prostatectomy  bear  the  operation,  as  a  rule,  surprisingly  well,  even 
though  the  manipulations  seem  to  be  somewhat  prolonged.  This  I  take 
it  is  due  to  the  little  loss  of  blood  that  attends  the  work,  and  to  the 
elevated  position  of  the  pelvis  and  lower  limbs  which  is  maintained 
during  its  progress.  In  the  feebler  patients,  however,  a  later  depression 
has  in  some  cases  manifested  itself  after  the  operation.  This,  however, 
soon  disappears  under  the  use  of  heat,  hypodermoclysis,  and  adrenalin. 

The  same  tendency  toward  renal  insufficiency  occurs  after  the  perineal 
operation  as  after  the  transvesical  and  should  be  guarded  against  by 
preliminary  treatment. 

Results  of  the  Perineal  Operation. — The  best  results  that  can  be 
expected  in  the  most  expert  hands  are  an  immediate  mortality  of 
between  3  and  6  per  cent.  In  a  series  of  twenty-one  cases  of  our 
own,  men  ranging  from  fifty-five  to  eighty  years  of  age,  there  were 
two  deaths — 9  per  cent,  mortality. 

Relief  of  Obstruction. — In  our  own  series  of  cases  we  had  complete  and 
permanent  relief  of  obstruction  with  the  exception  of  one  case  which 
was  of  the  contracted  fibrous  type,  in  which  we  did  not  entirely  remove 
the  obstruction. 

Fistulas. — A  persistent  recto-urethral  fistula  remained  in  one  of  our 
cases.  In  all  of  the  others  complete  and  sound  healing  of  the  wound 
took  place. 

Epididymitis. — This  occurred  six  times  in  the  course  of  healing  in  a 
series  of  twenty-one  cases. 

Continence  of  Urine. — The  control  of  the  bladder  sphincters  prevent- 
ing involuntary  escape  of  urine  is  regained  in  great  measure  within 
from  ten  to  twenty  days  after  operation.  Some  weakness  of  the 
sphincters,  resulting  hi  slight  leakage,  if  the  patient  cannot  at  once 
respond  to  calls  to  empty  the  bladder,  continues  to  manifest  itself  for 
months  in  some  cases,  but  is  gradually  replaced  by  normal  control  in 
most  of  the  cases.  In  some  instances,  however,  this  weakness  continues 
permanently,  but  entails  an  infirmity  so  much  less  than  the  preexisting 
dysuria  that  the  patient  bears  it  cheerfully. 

Conclusion. — In  our  own  experience  the  results  have  justified  the 
expectations  which  the  representations  of  other  surgeons  have  created 
and  the  perineal  operation  may  be  considered  as  a  fairly  safe  and  rea- 
sonably certain  means  of  relief.  It  is  necessary,  however,  that  the 
operation  be  done  by  a  surgeon  of  experience  and  that  he  should  employ 
a  full  exposure  of  the  gland  in  the  wound  at  operation.  As  an  operation 
to  be  performed  by  the  general  surgeon  it  cannot  be  compared  in  safety, 
in  freedom  from  accidents  and  in  the  certainty  of  the  results,  with  the 
two-stage  transvesical  prostatectomy. 


ENLARGEMENT  OF  PROSTATE 


647 


Perineal  Prostatectomy  through  a  Median  Incision. — Finger  Enuclea- 
tion  through  an  External  Perineal  Urethrotomy  Incision. — This  method 
has  been  extensively  practised  and  is  strongly  recommended  by  Watson18 
as  the  preferred  method  in  the  majority  of  cases. 

Technic. — A  vertical  median  incision  is  made  similar  to  the  one  used 
in  performing  a  median  perineal  external  urethrotomy.  The  dissection 
exposes  the  anterior  end  of  the  membranous  urethra.  Watson  describes 
the  steps  of  the  operation  as  follows: 


FIG.  322. — Finger  introduced  into  the  prostatic  urethra  and  about  to  begin  the 
enucleation.     (Watson.) 

Operation. — Pass  the  grooved  staff  into  the  bladder  and  make  it 
prominent  in  the  middle  line  of  the  perineum.  If  there  is  special 
difficulty  in  passing  the  sound  into  the  bladder,  because  of  the  obstruc- 
tion offered  by  the  prostate,  it  should  not  be  carried  beyond  the 
posterior  end  of  the  membranous  urethra.  This  serves  the  purpose  for 
which  the  sound  is  used  just  as  well  as  though  it  were  passed  into  the 
bladder  (Figs.  322  and  323). 


648 


PROSTATIC  OBSTRUCTIONS 


Expose  the  bulbous  and  the  anterior  part  of  the  membranous  urethra 
by  a  median  incision.  Open  the  posterior  end  of  the  membranous  and 
anterior  end  of  the  prostatic  urethra  by  a  straight,  narrow  bistoury, 
using  the  nail  of  the  index  finger  placed  in  the  groove  of  the  staff  as 


FIG.  323.- 


-Enucleation  through  a  median  external  perineal  urethrotomy  incision. 
(Watson.) 


a  guide.  The  cutting  edge  of  the  knife  should  be  directed  upward. 
Withdraw  the  staff.  Pass  into  the  incision  in  the  urethra  and  through 
the  prostatic  urethra  into  the  bladder  three  steel  sounds,  the  little 
finger,  and  the  index  finger  in  succession  (see  Fig.  322). 


ENLARGEMENT  OF  PROSTATE' 


649 


Push  the  prostate  toward  the  surface  of  the  perineum  and  maintain 
it  firmly  in  this  position  by  strong  downward  pressure  upon  the 
abdominal  wall  made  by  the  hand  of  an  assistant. 

The  index  finger  is  pushed  into  the  prostatic  urethra  and  turned 
upward  so  that  its  dorsum  rests  on  the  floor  of  the  canal  (Figs.  322 
and  323). 


FIG.  324. — Young's  technic:   Prostate  brought  down  and  lateral  incisions  made  in 
capsule.     (After  Young.) 

Press  the  finger-tip  against  the  side  of  the  urethra  above  its  floor  and 
make  an  opening  about  midway  in  its  length,  through  the  urethra  and 
all  tissues  intervening  between  it  and  capsula  vera  of  the  lobe  of  that 
side  of  the  gland. 

Proceed  to  enucleate  thus:  Pass  the  finger-tip  beneath  the  posterior 
surface  of  the  lobe,  between  it  and  the  outer  fibrous  sheath  (Fig.  323), 
and  break  down  the  fibers  attaching  it  to  the  gland  Carry  the  finger 


650 


,    PROSTATIC  OBSTRUCTIONS 


over  the  outer  and  superior  aspects  of  the  lobe  as  far  as  the  middle  line 
above — anterior  commissure.  Go  back  and  free  the  aspect  of  the  lobe 
from  its  attachment  to  the  triangular  ligament.  Then  separate  the  base 
of  the  lobe  from  the  floor  of  the  bladder  and  its  outlet.  If  the  gland  is 
to  be  removed  one  lobe  at  a  time,  break  through  the  anterior  com- 
missure and  separate  what  remains  attached  to  the  prostatic  urethra. 
This  leaves  the  first  lateral  lobe  free.  Apply  forceps  to  it  and  gently 
withdraw  it  through  the  external  incision. 

If  the  two  lobes  are  to  be  removed  in  one  mass,  the  finger-tip  passes 
over  the  anterior  commissure,  instead  of  breaking  through  it,  and 


FIG.  325.— Yi 


chnic:  Separation  of  capsule  with  blunt  dissector.      (After  Young.) 


repeats  the  same  maneuvers  with  the  second  lobe  that  were  employed 
to  free  the  first  one.  Care  should  be  taken  to  avoid,  so  far  as  possible, 
laceration  of  the  membranous  urethra  in  withdrawing  large  masses 
through  the  external  wound. 

If  a  middle  lobe  is  present,  the  mucous  membrane  covering  it  should 
be  split,  scratched,  or  cut  through,  either  in  the  middle  line  above  or 
along  one  side  of  the  enlargement,  and  enucleated  with  the  finger,  the 
lobe  cut  away  with  scissors,  or  snared  off.  It  can  be  brought  within  reach 
of  the  finger-tip  by  downward  pressure  from  above  the  symphysis  upon 
the  external  surface  of  the  abdomen,  as  in  the  case  of  the  lateral  lobes, 


ENLARGEMENT  OF  PROSTATE 


651 


or,  after  the  latter  have  been  removed,  it  is  readily  hooked  down  with 
the  finger-tip. 

The  methods  of  drainage  of  the  bladder  and  wound  are  similar  to 
those  recommended  in  the  other  type  of  perineal  operation. 

This  method  of  removing  the  prostate  does  not  recommend  itself  to 
the  majority  of  surgeons.*  It  is  more  difficult  of  performance,  more 
uncertain  in  the  completeness  of  its  removal  of  the  obstruction,  and 
the  chances  of  accident  and  unpleasant  sequelae  are  far  greater  than  is 
the  case  in  a  properly  executed  transvesical  prostatectomy. 


FIG.  326. — Young's  technic:    Withdrawing  lateral  lobes  after  being  enucleated. 

(After  Young.) 

Difficulties  Encountered  during  the  Course  of  Prostatectomy. — Difficul- 
ties in  the  approach  to  the  prostate  are  problems  of  general  surgical 
interest  and  do  not  need  special  mention  here,  but  there  are  a  small 
percentage  of  the  cases  (not  more  than  10  per  cent,  and  not  less  than 
5  per  cent.)  in  which  irregularities  in  the  form  and  attachments 
of  the  hyperplastic  tissues  are  such  that  their  safe  and  complete 
removal  requires  all  the  ingenuity  that  an  experienced  surgeon  'can 


*  This  is  partly  because  of  it  being  performed  by  the  sense  of  touch  alone  and  partly 
because  it  is  thought  by  many  that  its  final  results  are  not  as  good  as  those  attained 
by  other  technics.  It  is,  however,  as  safe  and  complete  as  any  of  the  methods. 


652 


PROSTATIC  OBSTRUCTIONS 


apply.  The  writer  has  been  surprised  to  learn  from  time  to  time 
that  surgeons  have  contented  themselves  in  difficult  cases  with  a 
partial  removal  of  the  prostate,  not  feeling  sure  at  the  end  of  a 
difficult  attack  that  the  obstruction  itself  has  been  in  any  way 
relieved.  This  is  almost  inexcusable  today,  unless  the  case  is  unques- 
tionably one  of  malignant  infiltration.  Under  difficult  conditions 
where  the  finger  enucleation  has  proved  unsatisfactory,  the  bladder 
should  be  widely  opened  and  the  prostatic  area  exposed,  and  a  careful 
dissection  made  of  the  obstructing  mass  irrespective  of  whether  or  not 


FIG.  327. — Young's  technic:    Manner  of  removing  middle  lobe.     (After  Young.) 


the  internal  sphincter  of  the  bladder  is  removed.  It  is  better  to  remove 
the  internal  sphincter  with  an  adherent  infiltrating  mass,  even  though 
it  might  result  in  a  faulty  control  of  the  urine,  than  to  leave  it  with  an 
obstructing  mass  which  would  cause  urinary  stasis  and  continue  the 
suffering  from  the  disease.  The  manner  of  proceeding  under  such 
circumstances  must  be  left  to  the  individual  surgeon. 

Occasionally  the  operator  meets  with  a  case  in  which  there  is  an 
enormous  enlargement  of  the  prostate.  The  writer  has  in  mind  a  few 
cases  in  which  the  hyperplastic  masses  of  tissue,  while  not  unduly 


ENLARGEMENT  OF  PROSTATE  653 

adherent,  were  enormously  multiplied  in  number,  forming  an  irregular 
mass  which  almost  filled  the  pelvis,  extended  beneath  the  trigone,  and 
obstructed  the  rectum.  One  feels  that  all  of  this  hyperplastic  mass 
must  be  removed,  but  in  one  case  operated  upon  by  the  writer  he 
believes  that  by  so  doing  the  life  of  the  patient  was  sacrificed,  whereas 
the  removal  of  the  masses  occupying  more  directly  the  outlet  of  the 
bladder  might  have  resulted  in  the  recovery  of  the  patient  with  an 
amelioration  of  his  symptoms.  So  that  the  surgeon  is  warned  in  cases 
where  he  feels  that  the  operation  is  too  prolonged  and  the  loss  of  blood 
is  becoming  .a  serious  factor  in  the  patient's  condition,  that  he  should 
be  content  with  removing  the  portion  of  the  gland  causing  the  obstruc- 
tion and  leaving  the  other  masses  for  further  operation  if  obstructive 
symptoms  recur. 

The  Correction  of  Defects  which  are  the  Result  of  Prostatectomy. — 
Extensive  tearing  or  injury,  if  it  occurs  during  the  course  of  prostatic 
enucleation,  should  be  immediately  repaired.  This  refers  to  a  lacera- 
tion of  the  rectal  wall,  the  peritoneum,  or  undue  injury  to  the  bladder 
wall  or  sphincters.  One  will  never  again  have  so  good  an  opportunity 
to  do  so  as  the  time  of  operation.  The  closure  of  fistulae  and  correc- 
tion of  strictures,  if  they  should  occur,  are  subjects  treated  in  other 
sections  of  this  work.  It  may  be  well  to  say  that  in  cases  where  re- 
operation  is  to  be  done  through  scar  tissue,  the  chances  of  success,  or  a 
near  approach  to  normal  condition,  is  not  good. 

Secondary  Operation  in  Cases  of  Recurrence  of  Obstructive  Symptoms. — 
Every  urologist  of  experience  will  attest  the  fact  that  the  return  of 
obstructive  symptoms  after  removal  of  the  hyperplastic  portion  of  the 
prostate  is  a  very  rare  occurrence  provided  the  operation  has  been 
done  by  a  skilled  surgeon  in  a  case  where  the  obstruction  was  due  to 
non-malignant  disease  of  the  prostate  or  the  associated  glandular 
groups. 

If  obstructive  symptoms  appear  soon  after,  or  within  two  years  after 
the  removal  of  the  growth,  the  surgeon  immediately  suspects  the 
presence  of  cancer.  Cancer  of  the  prostate  occurs  sometimes  in  such 
forms  that  its  presence  is  not  discovered  at  the  time  of  the  removal  of 
the  gland. 

There  are  certain  cases  in  which  it  is  impossible  to  remove  all  of  the 
obstructive  tissue  and  still  preserve  the  life  of  the  patient.  In  such 
cases  we  may  expect  the  return  of  obstructive  symptoms,  but  are  often 
surprised  at  the  completeness  of  relief  that  is  sometimes  secured. 
When  obstructive  symptoms  do  recur,  they  usually  are  associated  with 
more  pain  than  with  the  original  lesion,  while  the  amount  of  stasis  may 
not  be  so  great  and  the  amount  of  renal  destruction  may  not  be  so 
apparent. 

To  those  who  have  not  met  with  such  a  condition,  the  recital  of  a 
single  case  may  be  instructive. 

ILLUSTRATIVE  CASE  RECORD. — The  patient  was  a  man  sixty-five  years 
of  age,  who  had  developed  typical  symptoms  of  prostatic  obstruction 
for  which  he  was  operated  by  the  suprapubic  route  by  a  surgeon  who 


654  PROSTATIC  OBSTRUCTIONS 

rarely  operated  in  these  cases.  The  patient  recovered  well  from  his 
operation,  but  his  relief  lasted  but  a  short  time. 

Three  years  after  the  original  operation  he  presented  himself  suffering 
from  painful  urination,  nocturnal  frequency,  shooting  pains  radiating 
to  the  rectum  and  to  the  meatus,  and  more  or  less  continual  distress 
in  the  bladder. 

Examination  revealed  that  the  urethra  was  still  obstructed.  It  was 
impossible  to  pass  any  instrument  larger  than  16  of  the  French  scale. 
There  were  also  false  passages  in  the  urethra.  Rectal  examination 
showed  that  there  was  some  prostatic  tissue  present  in  the  region  of  the 
urethra  and  of  the  left  seminal  vesicle. 

The  fact  that  he  had  lived  three  years  without  loss  of  flesh  and 
strength  and  without  a  hard  mass  being  present  and  palpable  per 
rectum  made  us  feel  that  the  growth  was  not  malignant,' but  rather 
a  fibrous  infiltrated  mass  of  prostatic  tissue  which  had  been  overlooked 
in  the  original  operation.  It  was  recommended  that  the  bladder  be 
opened  and  the  tissue  cleared  out  from  the  neck  of  the  bladder,  and  the 
sphincter  freed  of  all  prostatic  masses.  Operation  was  undertaken. 

Approach  to  the  Bladder. — Incision  was  made  through  the  previous 
scar,  carried  well  up  toward  the  umbilicus,  the  scar  tissue  was  gradu- 
ally dissected  away  until  the  bladder  was  reached .  Then  the  peritoneal 
fold  was  dissected  up,  freeing  a  goodly^portion  of  the  anterior  surface  of 
the  bladder.  A  laparotomy  sponge  w^as  placed  in  the  upper  angle  of 
the  wound,  the  bladder  wall  held  by  stay  sutures.  The  bladder 
was  opened  and  a  rough  calculus  with  characteristics  of  the  urate 
and  oxalate  type,  one  and  a  quarter  inches  in  length  and  half  an  inch 
in  diameter  was  removed.  Then  the  urethral  orifice  was  sought  and 
found  to  consist  of  a  sharply  defined  ring  perfectly  smooth  on  the 
vesical  surface  with  sharp-cut  edges  causing  a  constriction,  but  seemingly 
not  a  complete  stricture.  The  bladder  wall  was  quite  thin,  but  not  as 
much  trabeculated  as  would  be  expected  if  there  had  been  very  much 
obstruction  present. 

The  question  arose  in  the  writer's  mind  when  he  saw  the  thinness  of 
the  bladder  wall,  whether  the  stone  alone  were  the  cause  of  the  symp- 
toms, or  whether  they  were  due  to  the  obstruction  of  the  urethra. 
However,  it  seemed  to  him  that  his  duty  was  to  remove  the  obstruc- 
tion in  the  urethra  sufficiently  to  pass  a  good-sized  sound  into  the 
bladder. 

One  prostatic  mass  was  attached  to  the  internal  meatus.  This  was 
of  distinctly  fleshy  consistency,  evidently  prostatic  tissue.  It  passed 
downward  under  the  trigone.  It  was  attached  along  the  border  of  the 
sphincter  by  adhesions  and  was  densely  adherent,  requiring  a  very  great 
effort  to  loosen  it.  Then  a  second  mass  was  found  nestling  along  the 
urethra  partly  on  the  left  side  and  partly  beneath  the  urethra  on 
the  surface  of  which  was  seen  scar  tissue*  This  was  removed  with 
considerable  difficulty.  There  remained,  well  off  to  the  side  and 
posteriorly  running  downward  under  the  trigone,  another  mass  which 


ENLARGEMENT  OF  PROSTATE  655 

seemed  to  be  connected  with  the  seminal  vesicle.  This  also  contained 
nodular  masses.  It  was  removed.  It  was  not  as  densely  adherent  as 
the  previous  specimens  had  been  and  did  not  seem  to  embarrass  the 
action  of  the  sphincter  as  much. 

This  left  us  with  the  sphincter  entirely  free  and  with  the  urethral  open- 
ing clear  of  obstructions.  A  sound  was  passed  through  the  urethra  and 
it  was  found  that  there  was  an  obstruction  about  six  inches  from  the 
meatus  due  to  cicatricial  tissue.  This  was  incised.  Then  a  large 
button  drainage  tube  "was  introduced  through  the  urethra  to  drain  the 
bladder  from  below  and  to  favor  the  formation  of  a  new  urethra.  The 
bladder  was  closed  with  a  running  chromic  gut  suture,  leaving  a  small 
opening  at  the  top  for  a  de  Pezzer  catheter.  The  original  suture 
closing  the  bladder  was  retained  in  order  to  invert  the  first  sutures. 
The  muscles  and  fascia  were  brought  together  with  chromic  gut  suture 
and  the  wound  closed  with  silk. 

After-history. — Recovery  of  the  patient  was  marred  by  a  slow  closure 
of  the  suprapubic  wound;  complete  recovery  was  finally  secured.  One 
year  later  this  patient  reports  that  he  is  in  perfect  health  with  no  return 
of  his  original  symptoms. 

The  case  is  cited  as  of  importance  in  encouraging  reoperation  in 
cases  where  the  first  one  has  been  apparently  a  failure. 

Causes  of  Death  following  Operation. — Much  has  been  written  and 
many  statistics  have  been  compiled,  but  the  ultimate  conclusions  of 
most  observers  are  the  same,  namely,  that  the  most  frequent  cause  of 
death  following  operation  for  prostatic  obstruction  is  primarily  renal 
insufficiency.  The  second  most  frequent  cause  of  death  is  hemorrhage 
combined  with  surgical  shock.  It  is  safe  to  say  that  fully  two-thirds 
of  the  deaths  following  operation  are  caused  by  one  of  these  two  factors. 
Wade  and  some  of  the  other  observers  are  inclined  to  believe  that 
most  of  the  deaths  are  due  to  local  infection  and  acute  suppurative 
nephritis.  Unquestionably  some  of  the  deaths  are  due  to  these  causes, 
but  certainly  few,  if  any,  of  those  which  occur  during  the  first  week 
after  prostatectomy  are  due  to  acute  suppurative  nephritis  or  local 
infection  of  the  wound.  The  men  who  believe  this  to  be  the  cause  of 
death  in  most  instances  acknowledge  that  the  cases  upon  which  they 
base  their  judgment  have  seldom  lived  more  than  a  week  after  the 
operation. 

Sepsis  undoubtedly  plays  a  part  in  the  mortality  records,  but  its 
importance  has  been  greatly  reduced  by  an  appreciation  of  the  impor- 
tance of  preliminary  treatment  before  prostatectomy  is  attempted. 

Embolism  in  some  form  or  other  is  the  fourth  most  important  cause 
of  death  following  operation.13 

From  a  study  of  the  reported  cases  it  is  evident  that  the  percentage 
of  deaths  increase  with  the  age  of  the  patient.  Also  that  the  longer 
the  obstruction  has  existed  the  greater  the  percentage  of  deaths  from 
uremia  and  hemorrhage. 


656  PROSTATIC  OBSTRUCTIONS 


BIBLIOGRAPHY. 

1.  Bugbee:     High  Frequency  Current  in  Treatment  of  Tumors  of  Bladder,  etc., 
Internat.  Abst.  of  Surgery,  December,  1915,  pp.  581-593. 

2.  Cabot,  Hugh,  and  Crabtree,  E.  Granville:     The  Mechanism  of  the  Protection 
Afforded  by  the  Drainage  of  Prostatics  as  a  Preliminary  to  Operation. 

3.  Hagner:     Surg.,  Gyn.  and  Obst.,  xix,  555. 

4.  Lower:     A  Technic  for  Performing  Shockless  Suprapubic  Prostatectomy,  Ann. 
Surg.,  February,  1914. 

5.  Lower:     Trocar  and  Cannula  for  Suprapubic  Drainage  of  Bladder,  Urological  and 
Cutaneous  Review,  1914,  No.  1,  vol.  xviii. 

6.  Lowsley:     The  Human  Prostate  Gland  in  Youth,  Med.  Rec.,  September  4,  1915. 

7.  Lowsley:     Jour.  Am.  Med.  Assn.,  January  11,  1913,  p.  110. 

8.  Mouillin:     Enlargement  of  the  Prostate,  p.  135. 

9.  Pilcher,  P.  M.:     Ann.  Surg.,  April,  1914. 

10.  Pilcher,  P.  M.:     Transvesical  Prostatectomy  in  Two  Stages,  Ann.  Surg.,  April, 
1914. 

11.  Squier:     Vital  Statistics  of  Prostatectomy,  Surg.,  Gyn.  and  Obst.,  p.  433. 

12.  Tandler    and    Zuckerkandl:     Folia    Urologica,    Internationales    Archiv    fur    die 
Krankheiten  der  Harnorgane,  March,  1911. 

13.  Tenney  and  Chase:     Mortality  after  Prostatectomy,  Boston   Med.   and  Surg. 
Jour.,  clxxii,  No.  12,  437. 

14.  Wade,  H.:     Prostatism.     The  Surgical  Anatomy  and  Pathology  of  the  Operative 
Treatment,  Ann.  Surg.,  March,  1914,  lix,  No.  3,  p.  321. 

15.  Wallace:     Prostatic  Enlargement,  p.  134. 

16.  Watson  and  Cunningham:    Diseases  and  Surgery  of  the  Genito-urinary  System, 
Vol.  I,  Chap.  12.     Lea  &  Febiger,  Philadelphia,  1908. 

17.  Wilson  and  McGrath:     Surgical  Pathology  of  the  Prostate,   Surg.,   Gyn.   and 
Obst.,  December,  1911,  pp:  647-681. 

18.  Young:     Trans.  International  Assn.  of  Urology,  1911,  Jour.  Am.  Med.  Assn., 
January  25,  1913,  vol.  Ix. 


CHAPTER  XX. 
CANCER  OF  THE  PROSTATE. 
BY  HUGH  HAMPTON  YOUNG,  M.D. 

CANCER  of  the  prostate  has  until  recent  years  been  considered  an 
infrequent  disease.  The  first  statistics  as  to  the  frequency  was  appar- 
ently an  article  by  Tanchou,  who  analyzed  8289  cases  of  cancer  in  Paris 
between  the  years  1830  and  1840  and  found  only  5  cases  diagnosed 
cancer  of  the  prostate. 

Gross,  in  Philadelphia,  was  one  of  the  first  to  furnish  definite  data  in 
regard  to  cancer  of  the  prostate  about  1850,  but  it  was  not  until  Sir 
Henry  Thompson,  in  1861,  in  his  monumental  work  on  the  Diseases 
of  the  Prostate,  recognized  the  importance  and  predicted  the  future 
frequency  of  the  disease. 

Thompson  published  12  cases,  and  remarked  that  cancer  of  the  pros- 
tate was  probably  overlooked  frequently,  especially  in  the  more  chronic 
forms  or  indeed  where  it  developed  in  an  already  hypertrophied 
prostate. 

Von  Recklinghausen  contributed  greatly  to  the  subject  by  demon- 
strating that  osseous  metastases  not  infrequently  came  from  cancer  of 
the  prostate  which  was  often  unrecognized. 

The  disease  was  nervetheless  considered  rare.  Socin  and  Burck- 
hardt,  in  their  splendid  book  Krankheiten  der  Prostata,  in  1902,  even 
held  it  was  seldom  met  with,  until  Albarran  and  Halle  published  their 
"discovery"  of  14  casesof  carcinoma  in  lOOsupposedly  benign  prostates, 
and  brought  to  the  attention  of  the  surgical  world  the  considerable 
frequency  of  cancer  of  the  prostate.  This  was  followed  by  papers  by 
Motz,  Kaufmann,  Hawley,  Young,  Pousson,  Montfort,  Hallopeau, 
Kummell,  Freyer,  McGrath,  Wildbolz,  Verhoogen,  Schapiro,  and 
Willms,  thus  leading  to  a  much  greater  concentration  of  interest  in  and 
wider  diffusion  of  knowledge  of  cancer  of  the  prostate. 

Frequency. — Statistics  vary  as  to  the  general  frequency  of  cancer  of 
the  prostate.  In  the  studies  from  the  records  of  the  Institute  of 
Anatomy  in  Munich  there  were  29  cases  of  cancer  of  the  prostate  in 
5777  autopsies,  or  2  per  cent.,  whereas  in  Brussels  there  were  only  0.7 
per  cent,  among  all,  or  1.8  per  cent,  among  males.  In  the  last  fifteen 
years  cancer  of  the  prostate  has  been  accorded  an  increasingly  important 
role  and  frequency  as  compared  with  hypertrophy  of  the  prostate. 

As  remarked  above  in  1900,  Albarran,  in  a  study  of  100  specimens  of 

prostatic  hypertrophy  in  the  Musee  Guyon,  discovered  malignant 

changes — "epithelioma  adenoide" — in   14  cases.     This  caused   Ger- 

aghty  and  myself  to  study  our  clinical  and  pathological  material  thor- 

M  u    i—42  (  657  ) 


658  CANCER  OF  THE  PROSTATE 

oughly,  and  whereas  we  were  unable  to  confirm  Albanian's  findings,  I 
was  able  to  show  a  far  greater  clinical  frequency  for  carcinoma  of  the 
prostate  than  had  been  recognized  previously  (21  per  cent.). 

I  made  the  statement:  "In  the  five  years  between  1902  and  1907 
I  have  seen  250  cases  of  benign  hypertrophy  and  68  cases  of  carcinoma 
of  the  prostate  (21  per  cent.).  I  am  aware  that  my  figures  attribute  to 
cancer  a  more  frequent  occurrence  than  any  other  in  the  literature,  but 
I  believe  they  represent  the  true  condition." 

Since  then  there  have  been  numerous  confirmatory  publications: 
Oliver  Smith's  statistics  gave  a  proportion  of  16  per  cent.,  Davis  20 
per  cent.,  Moullin  25  per  cent.,  Kummell  20  per  cent.,  Pauchet  20 
per  cent.  At  the  Institute  of  Pathology  in  Munich  among  103  deaths 
from  "prostatic  accidents"  there  were  found  27  cancers.  Wilson  and 
McGrath  studying  468  prostatectomy  specimens  removed  at  the  Mayo 
Clinic,  found  that  73  were  cancer  or  15.5  per  cent.  Freyer  has  recorded 
clinical  diagnoses  of  cancer  in  171  cases  among  1276  cases  of  prostatic 
enlargement  or  13.4  per  cent.  Microscopic  examination  of  his  opera- 
tive specimens  has  not  been  carried  out  in  all  cases,  so  the  percentage 
may  be  higher. 

These  statistics  are  sufficient  to  show  that  cancer  of  the  prostate  is  a 
fairly  common  disease,  and  a  very  important  problem  in  the  surgery  of 
the  prostate,  especially  as  the  importance  of  early  diagnosis  and  radical 
excision  has  been  so  conclusively  demonstrated. 

Etiology. — The  etiology  of  cancer  of  the  prostate  is  as  obscure  as  that 
of  cancer  in  general.  It  appears  at  about  the  same  period  of  life  as 
hypertrophy — after  forty  years — and  most  frequently  between  sixty 
and  seventy  years  of  age. 

There  is  nothing  to  show  that  a  preceding  prostatitis  or  hypertrophy 
of  the  prostate  has  any  causative  relation,  although  both  frequently 
occur  with  cancer  of  the  prostate.  Our  studies  seem  to  show  conclu- 
sively that  "malignant  degeneration"  of  hypertrophied  lobes  does  not 
occur  frequently,  if  at  all,  and  the  lesions  which  Albarran  and  Halle 
described  as  malignant  changes,  "epithelioma  adenoide,"  in  otherwise 
benign  prostatic  enlargements  have  been  seen  so  often  in  other  con- 
ditions— manifestly  not  malignant — that  we  cannot  consider  them  to 
be  even  forerunners  of  cancer  of  the  prostate.  "Our  view  has  since  been 
confirmed  by  Tietze,  who  has  met  with  analogous  cellular  masses  in 
young  prostates,  and  attributes  to  them  an  important  role  in  the  de- 
velopment of  the  gland.  Casper,  Renge  and  others  have  described 
them  in  hypertrophy  of  the  prostate.  Finally,  Brault,  Menetrier,  and 
Darier,  who  have  studied  them  in  a  case  of  Pasteau,  do  not  consider 
them  as  epitheliomatous  but  as  tangential  cuts  of  normal  glandular 
masses."  (Verhoogen.)  Our  pathological  studies  (1915)  show  hyper- 
trophy present  with  cancer  in  61  per  cent,  of  the  cases  of  cancer  of  the 
prostate. 

Studies  made  in  1906  seemed  to  show  that  prostatic  hypertrophy 
was  largely  a  disease  of  married  men.  At  that  time  I  remarked  that  in 
corroboration  of  this  I  had  never  seen  a  case  of  enlarged  prostate  in  a 


PATHOLOGY 


659 


Catholic  priest,  although  there  had  been  many  cases  among  married 
Protestant  ministers.  Since  then  two  priests  with  enlarged  prostates 
have  been  encountered,  but  both  were  cancer. 

Pathology. — As  remarked  above  we  feel  convinced  that  carcinoma  of 
the  prostate  does  not  result  as  a  degeneration  of  the  previously  benign 
adenomatous  process ;  that  in  about  half  of  the  cases  it  develops  where 
no  hypertrophy  is  present;  that  in  such  cases  the  prostate  is  often  little 
if  at  all  enlarged ;  that  the  carcinomatous  growth  follows  planes  of  least 
resistance;  that  it  is  very  slow  in  invading  fibrous  capsules  (Fig.  328), 
both  of  the  prostate  itself  and  also  of  hypertrophied  spheroids,  lobules 
or  lobes;  that  the  mucosa  and  submucosa  of  both  urethra  and  bladder 
are  also  very  resistant  to  it;  that  the  most  common  site  for  the  begin- 


FIQ.  328. — Showing  the  capsule  surrounding  adenomatous  hypertrophy   (above)  which 
has  resisted  extensive  adenocarcinoma  (below) . 

ning  of  cancer  is  in  the  posterior  subcapsular  stratum  or  lobe,  and  that 
from  there  it  may  invade  the  rest  of  the  prostatic  glandular  tissue  or  it 
may  travel  up\vard,  escaping  from  the  upper  end  of  the  prostate  in  the 
region  about  the  ejaculatory  ducts,  and  between  the  fascia  of  Denon- 
villiers  (Fig.  329)  posteriorly,  and  the  trigone  anteriorly;  that  in  its 
further  growth  the  seminal  vesicles  and  vasa  deferentia  may  not 
become  infiltrated,  but  in  some  cases  their  lumina  may  become  filled 
with  cancer  cells  and,  in  the  case  of  the  vasa  deferentia,  these  may 
extend  upward  for  a  long  distance,  the  outer  walls  of  the  vas  remaining 
apparently  intact ;  that  the  muscle  of  the  trigone  and  bladder  and  also 
the  peritoneum  may  be  invaded  from  this  subtrigonal  involvement; 
and,  finally,  that  the  fascia  of  Denonvilliers,  which  gives  the  prostate 


660  CANCER  OF  THE  PROSTATE 

its  most  dense  capsule  posteriorly,  is  a  most  effective  agent  in  pre- 
venting involvement  of  the  rectum  and  periprostatic  structures. 

Histology. — Perhaps  we  can  make  our  description  of  cancer  clearer  if 
we  first  give  our  impression  of  the  appearance  of  the  normal  prostate 
and  in  benign  hypertrophy. 

The  tissue  of  the  normal  prostate  is  rather  grayish  in  color  and  some- 
what moist.  It  is  soft  in  consistency,  but  tough.  On  pressure  a  small 
amount  of  prostatic  secretion  can  frequently  be  squeezed  out.  The 
cut  surface  is  apparently  smooth  and  homogeneous,  but  on  close  in- 
spection the  tiny  glandular  orifices  can  be  discovered.  Sometimes  the 
orifices  of  dilated  acini  are  very  evident. 


FIG.  329. — The  aponeurosis  of  Denonvillier's  which  covers  the  posterior  surface  of 
prostate,  seminal  vesicles,  vasa  deferentia;  here  partly  removed  to  show  these  structures. 
(After  Deaver.) 

The  tissue  of  benign  prostatic  adenoma  is  usually  quite  characteristic. 
It  has  a  lobular  appearance  due  to  the  formation  of  varying  sized 
spheroidal  tumors  often  definitely  encapsulated,  the  lobular  mass  as  a 
whole  being  compressed  by  a  more  or  less  well-developed  capsule 
formed  from  the  condensed  peripheral  prostatic  tissue.  The  tissue  is 
usually  elastic  or  soft  in  consistence,  and  on  section  is  moist.  Fre- 
quently large  quantities  of  a  milky  fluid  ooze  from  the  prostatic  acini. 
Many  of  the  lobules  have  a  moth-eaten  appearance  due  to  the  presence 
of  dilated  acini.  In  other  lobules  where  the  glandular  elements  are  not 
so  numerous,  and  the  stroma  predominates,  the  surface  is  rather  smooth 
and  slimy. 

Practically  no  difficulty  is  encountered  in  differentiating  carcinoma- 
tous  prostatic  tissue  from  the  tissue  of  hypertrophy  or  of  the  normal 
prostate,  presupposing  of  course  that  the  carcinomatous  area  is  of 
sufficient  size  to  be  discernible.  The  greatest  difficulty  arises  from  the 


HISTOLOGY  661 

tissue  of  a  long-standing  fibroid  prostatitis.  Carcinoma  is  usually  quite 
characteristic.  It  is  hard,  dense,  and  on  pressure  gives  very  little  sense 
of  elasticity  (which  is  generally  still  present  even  in  well-advanced 
fibroid  prostatitis) .  On  cutting  into  the  carcinoma  it  imparts  a  gritty 
sensation  to  the  knife  blade.  No  secretion  oozes  from  the  cut  surface, 
which  is  rather  homogeneous,  lacking  the  lobulation  so  characteristic  of 
hypertrophy.  Occasionally  where  the  cancer  has  invaded  a  previously 
benign  adenoma  an  indefinite  lobulation  may  persist  in  this  tissue,  but 
it  is  seldom  confusing. 

The  finer  details  of  the  cut  surface  vary.  Sometimes  irregularly 
interlacing  translucent  bands  of  varying  size  are  seen  with  small  gray- 
ish-yellow islands  scattered  here  and  there,  the  translucent  bands  being 
fibrous  in  character,  and  the  yellowish  areas  accumulations  of  cancer 
cells.  This  appearance  is  not  present  in  fibroid  prostatitis,  in  which  the 
epithelial  elements  practically  disappear,  and  the  surface  is  much  more 
smooth  and  homogeneous  than  in  cancer.  Where  the  cancer  is  infil- 
trating in  character,  fine  alternating  translucent  and  yellowish  lines 
can  frequently  be  seen  by  the  aid  of  a  small  magnifying  lens.  Usually 
one  can  be  moderately  certain  of  the  cancerous  nature  of  the  tissue  from 
gross  inspection  alone.  When  the  operator's  knife,  in  making  the  cap- 
sular  incisions,  cuts  through  dense  tissue  which  does  not  bulge,  the 
edges  of  which  are  firm  and  rigid,  suspicion  should  be  at  once  aroused. 

If  after  passing  through  such  a  layer  of  hard  tissue  a  bulging  hyper- 
trophied  lobe  is  encountered,  the  diagnosis  of  coexistent  cancer  and 
hypertrophy  is  generally  justified.  The  capsule  of  the  average  hyper- 
trophy is  rarely  thick,  nor  is  it  so  dense  and  gritty  as  that  of  cancer. 

Microscopic. — The  histological  character  of  cancer  of  the  prostate  is 
very  variable,  being  greatly  modified  by  the  character  of  tissue  invaded 
and  age  of  cancer  and  the  method  of  extension. 

A  classification  according  to  type  of  cell  is,  as  a  rule,  impossible,  as 
no  one  type  is  preserved  throughout,  the  same  section  often  showing 
great  varieties  of  shapes  and  sizes.  In  our  2  cases  in  which  cancer 
areas  a  few  millimeters  in  diameter  were  discovered  in  the  specimens 
removed  at  operation  the  microscope  showed  a  definite  adenocarcinoma, 
but  in  one  of  these,  even  at  this  early  stage,  marked  infiltration  into  the 
stroma  had  begun. 

In  10  apparently  primary  cases  the  cancer  more  often  tended  toward 
the  scirrhous  type,  7  being  of  this  type  (Fig.  330).  In  3  cases  no 
glandular  formation  was  present;  in  the  other  4  cases  occasional  small 
groups  of  atypical  acini  were  seen,  but  the  great  bulk  of  the  tissue  was 
scirrhous.  At  times  the  fibrous  overgrowth  is  so  marked  that  epithelial 
elements  may  be  almost  wanting,  or  the  fibrous  stroma  is  so  dense  that 
the  cancer  cells  are  often  not  recognizable,  small  nuclear  specks  being 
alone  visible.  This  may  lead  to  error  of  diagnosis  if  only  a  small 
section  is  examined.  At  other  times  definite  masses  or  infiltrating  lines 
of  irregular-shaped  cancer  cells  are  seen,  the  size  and  shape  seeming  to 
depend  largely  upon  the  compressing  force  of  the  fibrous  stroma. 

Those  of  the  adenocarcinomatous  type  present  most  varying  pictures. 


662 


CANCER  OF  THE  PROSTATE 


At  times  acini,  formed  of  irregular  cells,  often  with  big,  deep-staining 
nuclei,  are  scattered  at  wide  intervals,  the  intervening  tissue  being  more 
or  less  densely  infiltrated  with  cancer  cells.  At  other  times  the  cancer 
acini  are  so  numerous  and  close  together  that  the  fibrous  stroma  may  be 
difficult  to  see.  The  acini  in  these  areas  are  usually  very  small  and 
lined  by  small  cylindrical  cells,  often  quite  irregular  in  shape  and  with 
small  rounded  nuclei .  Often  over  large  areas  no  attempt  at  a  glandular 
reproduction  occurs,  cancer  cells  simply  growing  aimlessly  through  a 
fibrous  stroma  (Fig.  331).  Occasionally  normal  acini  are  found 
persisting  in  large  areas  of  cancer. 


FIG.  330. — Scirrhous  form  of  adenocarciiionia. 


Cancer  of  the  prostate  spreads  in  two  ways,  by  direct  extension 
through  the  stroma  and  by  extension  along  the  ducts.  As  a  result  of 
this  duct  extension  one  sometimes  sees  masses  of  cancer  cells  filling  the 
acini,  the  intervening  tissue  being  entirely  normal. 

Cancer  Associated  with  Hypertrophy. — In  our  cases  in  which  cancer  and 
hypertrophy  were  present  together  (48  in  71  cancer  cases,  or  61  per 
cent.)  the  cancer,  as  remarked  before,  generally  forms  a  layer  beneath 
the  posterior  capsule,  and  the  hypertrophied  lateral  lobes  lie  in  front  of 
and  distinctly  separated  from  cancer  by  their  own  capsules  which  are 
generally  intact  (Fig.  332).  When  the  cancer  breaks  into  a  hyper- 
trophied adenomatous  lobule  it  spreads  rapidly  along  the  ducts,  thus 


CANCER  ASSOCIATED  WITH  HYPERTROPHY 


663 


giving  an  extremely  puzzling  picture  (Fig.  333)  of  glandular  acini  lined  or 


filled  with  cells  different  in  type  from  the  cells  of  the  ducts  or  acini  of  an 


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IllS^liP^^^^ 

\-j.0~~"'&)t?^~?    •  '"•••       '4'''!*'  >-'*-    '*-'  l"^~^'  '' 


^£_^. 

FIG.  331. — A  medullary  form  of  carcinoma  in  which  there  is  very  little  stroma  and  the 
cancer  cells  varying  in  size  and  shape  are  loosely  arranged. 


cap 


FIG.  332. — Transverse  section  in  front  of  verumontanum,  showing  two  large  hyper- 
trophied  lobes  on  each  side  of  the  urethra  and  thick  posterior  subcapsular  area  of  car- 
cinoma. Capsule  of  right  lateral  lobe  invaded  in  one  place  (cl). 


664 


CANCER  OF  THE  PROSTATE 


adenomatous  hypertrophy,  but  with  a  basement  membrane  often  intact 
and  a  normal  intervening  stroma.  Frequently  a  single  layer  of  cells 
will  reline  a  duct  or  acinus  so  that  except  for  the  character  of  the  cell 
the  acinus  looks  entirely  benign.  However,  we  have  never  seen  these 
broad  cylindrical  cells  with  clear,  pale-staining  protoplasm  and  nuclei 
centrally  placed  either  in  the  normal  or  the  hypertrophied  prostate. 
In  other  acini  the  cells  are  heaped  up  at  different  points  along  the  gland 


yy  N.ro.U. 


FIG.  333. — Showing  spread  of  the  carcinoma  by  way  of  the  ducts.  Solid  strands  of 
epithelial  cells  are  seen  growing  into  the  lumina  of  the  tubules  and  by  their  union  forming 
irregular  open  spaces.  There  is  no  infiltration  of  the  stroma. 

wall,  and  grow  across  the  lumina  sometimes  in  solid  masses,  but  more 
frequently  as  interlacing  strands  (Fig.  333) .  Sometimes  the  cancer  cells 
arrange  themselves  circularly,  leaving  a  central  lumen  as  if  in  an 
attempt  to  reproduce  a  gland  structure.  When  the  lumen  is  completely 
filled  the  cells  crowd  each  other  into  most  odd  and  peculiar  shapes. 

These  areas  of  duct  carcinoma  are  not  apt  to  be  mistaken  for  benign 
tissue  if  the  character  of  the  cells  is  noted.  Particularly  characteristic 


SYMPTOMS  665 

is  the  tendency  of  cancer  cells  to  grow  in  strands  across  the  lumen  of  the 
acinus  without  any  supporting  connective-tissue  framework.  This  does 
not  occur  in  hypertrophy.  In  the  latter  when  an  epithelial  budding 
from  the  wall  of  the  acinus  occurs,  it  is  quickly  followed  by  a  supporting 
stem  of  connective  tissue.  It  has  been  said  that  the  acini  of  the  normal 
or  hypertrophied  prostate  when  filled  with  desquamated  epithelial  cells 
may  be  difficult  to  differentiate  from  cancer  of  the  duct  type.  With 
exercise  of  ordinary  care  no  confusion  from  this  source  should  occur. 
Later,  with  the  advance  of  the  main  growth  through  the  stroma  or  the 
breaking  through  from  the  acini,  the  picture  is  changed.  The  tubules 
of  cancer  cells  with  a  more  or  less  densely  infiltrated  stroma  are  seen, 
sometimes  the  intervening  tissue  is  scirrhous,  sometimes  of  an  adeno- 
matous  type,  and  sometimes  the  cancer  cells  are  so  closely  packed  that 
a  fibrous  stroma  seems  almost  entirely  absent  and  a  medullary  form  of 
cancer  is  produced.  Sometimes  portions  of  the  cancer  seem  more  or 
less  definitely  alveolar.  When  the  cancer  invades  hypertrophied  lobes 
of  the  adenocystic  type,  in  which  the  interacinar  stroma  is  frequently 
small  in  amount,  the  picture  presented  is  that  of  cancer  cells  packed  in 
the  dilated  spaces,  resulting  in  an  alveolar  form  of  carcinoma  medullary 
in  character  (Fig.  331).  In  none  of  our  specimens,  either  primary  or 
those  associated  with  hypertrophy,  was  a  pure  adenocarcinomatous 
type  preserved  throughout.  Areas  of  adenocarcinoma  were  present, 
however,  in  great  or  less  degree,  in  practically  every  case  except  in  the 
three  cases  of  pure  scirrhus  previously  mentioned,  in  which  the  cancer 
occurred  in  a  prostate  not  previously  hypertrophied. 

Very  rarely  have  we  found  evidence  of  gross  or  microscopic  necrosis, 
no  matter  how  extensive  the  disease.  The  extensions  of  the  disease  to 
the  seminal  vesicles  and  bladder  are  usually  infiltrating  in  character, 
although  frequently  the  adenomatous  form  is  here  and  there  discov- 
ered. For  one  familiar  with  the  histological  character  of  the  normal 
and  hypertrophied  prostate,  the  microscopic  diagnosis  of  cancer  seldom 
entails  any  difficulty,  except  in  the  scirrhus,  where,  occasionally,  over 
small  areas,  the  fibrous  overgrowth  may  be  so  intense  that  no  definite 
epithelial  elements  are  recognizable,  small  scattered  nuclear  specks 
alone  being  visible.  However,  this  fibrous  density  is  of  itself  suspicious, 
and  a  section  from  a  different  area  will  usually  at  once  settle  this 
doubt. 

Symptoms. — From  a  surgical  stand-point  the  early  symptoms  in  car- 
cinoma of  the  prostate  are  the  important  ones,  and  unfortunately  a 
survey  of  the  literature  is  of  little  help  in  this  respect.  At  the  onset  it 
is  necessary  to  distinguish  between  early  and  late  cases. 

In  a  study  of  12  early  cases  I  found  it  necessary  to  make  three 
subdivisions. 

1.  Those  in  which  the  only  pathological  process  present  is  cancer, 
6  cases. 

2.  Those  in  which  cancer  is  associated  with  hypertrophy,  5  cases. 

3.  A  case  of  chronic  prostatitis  with  a  small  area  of  cancer  in  it. 


6<;r>  CANCER  Of  THE  PROSTATE 

Class  1  furnishes  the  most  satisfactory  group  for  study,  and  we  find 
the  following : 

Cases. 

Age  between  60  and  64  years 2 

65          69     " 2 

"70          74      " 1 

"75          79     " 1 

Duration  of  symptoms  before  admission : 

6  months 1 

1  year    . 2 

2  years  ..." '  •  .  .1 

3  years 2 

The  initial  symptoms  were  as  follows : 

Frequency  of  urination 1  case,  duration  2  years 

Difficulty  of  urination 1     "  "         1  year 

Urgency  of  urination 1      "  "         1     " 

Pain  in  penis  during  urination  1      "  "         1     " 

Frequency  and  difficulty  of  urination  .      .  2  cases,        "        each  3  years 

Subsequent  symptoms  were  present  as  follows:  Pain  in  the  penis  and 
perineum  came  on  two  years  later  in  1  case.  None  of  the  other  5 
patients  suffered  at  all  from  pain.  Hematuria  was  never  present  in  any 
of  the  6  cases. 

In  1  case  the  catheter  life  was  begun  eighteen  months  after  the  initial 
difficulty  of  urination  and  was  followed  for  eighteen  months  before 
admission.  The  other  5  patients  had  never  used  the  catheter. 

There  were  apparently  no  other  symptoms  present  in  these  6  cases, 
and  a  consideration  of  those  present  shows  there  was  nothing  diagnostic 
or  even  suggestive  of  cancer  present.  The  surprising  thing  is  that  in  4 
of  the  6  cases  symptoms  had  been  present  for  periods  of  two  years  or 
more.  The  fact  that  careful  pathological  examinations  of  the  lateral 
and  median  portions  of  these  prostates  failed  to  reveal  any  benign 
adenomatous  hypertrophy,  seems  to  point  to  carcinoma  as  being  the 
sole  cause  of  the  obstructive  symptoms  in  these  cases. 

The  complete  absence  of  hematuria  at  any  time  shows,  as  I  have 
pointed  out  before,  the  error  of  expecting  this  as  an  early  symptom.  It 
is  distinctly  more  common  in  benign  hypertrophies  (except  possibly 
late  in  the  disease) . 

Class  2.  The  5  cases  in  which  cancer  and  benign  hypertrophy  existed 
together  in  the  same  prostate  were  as  follows : 

Case      I.  Aged  60  years,  beginning  with  frequency  three  years  before. 
"       II.        "     69      "  "     frequency  six  months  before. 

"    III.        "     75      "  "     sudden  complete  retention  ten  months  before. 

"     IV.        "     78      "  "     frequency  four  years  before. 

"       V.        "     67      "  "  "     frequency  and  difficulty  two  and  a  half  years 

Ijefore. 

In  Case  I  there  was  pain  in  the  end  of  the  penis  before  and  during 
urination  and  in  Case  V  a  sciatica.  In  none  of  the  others  was  there 
ever  any  pain  present.  Hematuria  did  not  appear  in  any  case. 


SYMPTOMS  667 

Regular  catheterization  was  necessary  in  Case  V  for  one  year,  in  Case 
II  for  ten  months,  and  in  Case  IV  for  four  months.  In  Case  I  supra- 
pubic  drainage  became  necessary  three  years  after  onset. 

Class  3 .  The  case  in  which  chronic  prostatitis  was  present  along  with 
a  nodule  of  cancer  was  a  man,  aged  sixty-one  years,  who  had  for  fifteen 
years  had  symptoms  of  irritation  in  the  deep  urethra  and  attacks  of 
frequency  of  urination.  Catheterization  was  never  necessary  and 
hematuria  and  pain  were  never  present. 

In  conclusion  it  seems  from  a  study  of  the  above  early  cases  (and 
other  later  cases)  that  the  symptomatology  of  cancer  of  the  prostate  in 
the  early  stages  is  almost  identical  with  that  of  benign  hypertrophy,  so 
that  we  must  look  entirely  to  a  careful  physical  examination  to  furnish 
suspicion  of  cancer. 

The  Examination. — There  was  nothing  in  the  appearance  of  any  of 
these  twelve  patients  to  suggest  malignant  disease;  they  were  not 
emaciated  nor  were  they  suffering  pain,  with  the  exception  of  4  cases, 
and  in  these  it  was  not  severe.  The  urine  was  free  from  blood  in  all 
cases. 

In  the  6  cases  not  associated  with  hypertrophy  the  size  of  the  prostate 
was  described  as  considerably  enlarged  in  3  cases,  moderately  enlarged 
in  2  cases,  and  slightly  enlarged  in  1  case.  The  surface  was  smooth  in 
2  cases,  rough  in  3  cases,  nodular  in  3  cases.  Here  we  have  in  6  cases 
conditions  which  should  always  make  one  suspicious  of  cancer;  for  the 
benign  adenomatous  prostates,  unless  associated  with  considerable  in- 
flammation or  with  calculi  of  the  prostate,  are  nearly  always  smooth, 
though  they  may  be  lobulated.  The  consistence  was  described  as  very 
hard  in  all  of  the  6  cases  not  associated  with  hypertrophy,  and  in  some 
was  said  to  be  "  stony  hard."  In  5  cases  both  lobes  were  involved,  but 
in  1  case  the  left  half  of  the  prostate  was  normal.  In  this  interesting 
case  (in  which  an  urgency  of  urination  had  been  present  one  year)  the 
right  lobe  was  enlarged,  very  hard  and  rough,  the  induration  extending 
to  the  median  line,  where  it  ended  abruptly,  forming  a  straight  edge 
well  elevated  above  the  normal  left  half  of  the  prostate.  The  lower 
portion  of  the  right  seminal  vesicle  was  involved,  as  was  the  posterior 
part  of  the  membranous  urethra.  The  contrast  between  the  two  halves 
of  the  prostate  here  was  most  sharply  defined.  In  1  case  there  was  a 
hard  nodule  in  each  lobe,  which  was  otherwise  soft  on  each  side.  Two 
years  later  the  whole  prostate  was  rough,  irregular,  very  hard,  and 
greatly  enlarged.  In  the  other  4  cases,  although  in  2  symptoms  had 
been  present  only  one  year,  the  prostate  was  completely  invaded  by 
cancer  on  both  sides,  although  the  vesicles  were  mostly  free. 

In  a  recent  case,  not  tabulated  above,  the  first  examination  three 
years  ago  showed  a  nodule  1  cm.  in  diameter  in  the  left  lobe.  At  the 
next  examination  two  years  later  it  was  2  cm.  in  diameter,  and  one 
year  later  all  of  the  left  lobe  was  involved,  but  it  was  still  within  the 
prostatic  capsule.  This  case  shows  the  remarkably  slow  growth  in 
some  cases. 

The  5  cases  associated  with  hypertrophy  are  interesting:  In  Case  I 
(J.  T.  Y.,  No.  463)  the  prostate  was  considerably  enlarged,  smooth, 


668  CANCER  OP  THE  PROSTATE 

rather  hard  in  consistence.  Microscopic  study  showed  benign  hyper- 
trophy associated  with  prostatitis  on  both  sides,  with  only  one  small 
area  of  cancer  in  prostatic  tissue  which  was  the  seat  of  prostatitis. 

In  Case  II  (T.  C.  S.,  No.  2750),  in  which  symptoms  had  been  present 
only  six  months,  the  left  lobe  was  only  slightly  enlarged,  smooth,  and 
elastic.  On  the  surface  of  the  right  lobe  there  was  a  prominent  lobe 
1  cm.  in  size,  which  was  quite  hard,  but  seemed  elastic  on  pressure. 
(This  proved,  however,  to  be  entirely  cancerous.)  The  right  lobe  was 
otherwise  very  little  enlarged,  and  the  seminal  vesicles  were  not  in- 
durated, but  nevertheless  cancer  was  present  in  the  lower  portion  of  the 
left  seminal  vesicle.  The  left  lobe  when  removed  was  found  to  be  a 
benign  hypertrophy,  the  right  being  cancerous. 

In  Case  III  (W.  J.  R.,  No.  1779)  the  prostate  was  moderately  en- 
larged and  generally  indurated  (but  not  stony),  with  three  very  hard 
nodules  present,  one  in  the  median  line  near  the  apex,  one  at  the  upper 
end  of  the  left  lateral  lobe,  and  one  near  the  apex  of  the  right  lateral 
lobe.  Seminal  vesicles  negative.  At  operation  a  layer  of  cancer  be- 
neath the  posterior  capsule  was  found  on  the  left  side,  beneath  which 
was  a  benign  hypertrophied  lobe,  on  the  right  side  and  also  in  the 
median  portion,  benign  hypertrophied  lobes  were  removed. 

In  Case  IV  (J.  R.,  admitted  June  26,  1905)  the  prostate  was  moder- 
ately enlarged,  smooth,  the  right  lobe  was  elastic  and  only  slightly 
indurated.  Operation  showed  a  posterior  layer  of  cancer  with  a  hyper- 
trophied lobe  beneath.  The  left  lobe  was  smaller  and  softer,  and 
proved  to  be  benign  hypertrophy. 

In  Case  V  (E.  G.  W.,  No.  206)  the  prostate  was  considerably  en- 
larged, smooth,  but  very  hard.  Examination  showed  a  posterior 
subcapsular  layer  of  cancer,  with  benign  hypertrophy  in  front  of  it  on 
both  sides. 

A  review  of  these  5  cases  shows  that  the  presence  of  hypertrophy  of 
the  lateral  lobes  generally  gives  an  elasticity  to  the  prostate  on  deep 
pressure  which  is  very  deceptive.  In  these  cases  a  small  layer  or  nodule 
of  cancer  lying  between  the  capsule  and  an  hypertrophied  lobe  may  be 
compressible  on  deep  pressure.  More  delicate  palpation,  and  particu- 
larly palpation  upon  a  cystoscope  in  the  urethra,  will  often  show  the 
real  induration  of  the  local  carcinomatous  area. 

These  localized  areas  of  induration  or  nodulation  should  always  be 
suspected  and  subjected  to  early  perineal  operation. 

The  case  characterized  by  a  small  nodule  of  cancer  in  a  prostate 
which  was  the  seat  of  a  chronic  prostatitis  of  fifteen  years'  standing 
showed  on  rectal  examination  a  prostate  smooth,  slightly  indurated  and 
not  tender.  The  small  nodule  was  not  detected,  and  was  only  found 
accidentally  when  the  stained  sections  of  the  tissue  removed  were 
examined. 

The  clinical  examination  of  the  seminal  vesicles  in  these  12  early 
cases  shows  no  definite  invasion  of  these  structures.  In  1  case  only 
was  there  an  induration  for  a  short  distance  in  the  region  of  one  vesicle, 
but  subsequent  pathological  examination  (after  radical  operation) 
showed  that  the  carcinoma  had  not  penetrated  the  seminal  vesicles  as 


DIAGNOSIS  669 

supposed  but  lay  between  it  and  the  excised  trigone,  an  area  of  cancer 
1  cm.  long  being  present.  In  the  2  other  cases  in  which  the  radical 
operation  was  carried  out  only  the  juxtaprostatic  ends  of  the  seminal 
vesicles  and  vasa  deferentia  were  invaded. 

The  vesical  mucosa  was  normal  in  all  of  these  cases,  and  no  invasion 
of  the  trigone  was  present,  as  shown  by  the  cystoscope  and  at  operation. 

The  6  cases  in  which  no  coexistent  hypertrophy  of  the  prostate  was 
present  showed,  on  cystoscopic  examination,  only  a  small  median  bar 
with  no  intravesical  enlargement  of  the  lateral  lobes.  In  1  case  the 
median  portion  formed  a  small  sessile  lobe,  and  1  case  showed  both  a 
median  bar  and  a  slight  right  lateral  enlargement. 

The  characteristic  picture,  then,  in  early  cancer  of  the  prostate  is  a 
small  bar,  unaccompanied  by  marked  lateral  intravesical  enlargement. 

In  1  case  a  carcinomatous  constriction  of  the  prostatic  urethra  was 
present,  requiring  dilatation  before  cystoscopy  was  possible,  but  there 
was  no  evidence  of  ulceration  of  the  urethra  in  any  case. 

In  later  cases  stricture  of  the  prostatic  urethra  isliot  an  uncommon 
finding,  and  is  to  be  considered  very  suggestive  of  cancer. 

Diagnosis. — The  diagnosis  of  early  carcinoma  of  the  prostate  is  prin- 
cipally based  on  the  finding  of  great  induration  in  a  portion  of  the 
prostate,  as  shown  by  our  cases.  It  may  occur  as  one  or  more  small 
nodules  or  lobules  which  may  be  prominent  or  imbedded  in  the  prostatic 
tissue,  but  apparently  always  palpable  per  rectum.  In  later  cases  one 
whole  lobe,  or  both  lobes,  may  be  involved,  but  the  disease  apparently 
remains  well  encapsulated  for  a  fairly  long  period,  and  the  line  of  prog- 
ress is  upward,  beneath  the  fascia  of  Denonvilliers  (which  forms  the 
posterior  capsule  of  the  prostate  and  seminal  vesicles  (Fig.  329) ,  the 
ejaculatory  ducts  and  the  structures  between  the  lower  ends  of  the 
vasa  deferentia  and  the  bladder  being  invaded  after  the  cancer  cells 
pass  beyond  the  limits  of  the  prostate.  Induration  immediately  above 
the  prostate  and  easily  palpable,  with  a  finger  in  the  rectum  and  a 
cystoscope  in  the  urethra,  as  a  hard  subtrigonal  thickening,  is  of  great 
diagnostic  value.  In  later  cases  this  "  intervesicular  plateau"  of 
induration  becomes  more  and  more  pronounced,  but  it  is  remarkable 
how  long  the  upper  portions  of  the  seminal  vesicles  and  vesical  mucosa 
are  free  from  invasion. 

In  a  series  of  111  cases,  many  of  them  late  and  over  50  per  cent, 
associated  with  prostatic  hypertrophy  which  necessarily  modifies  the 
symptoms  and  the  progress  of  the  disease,  there  were  76  in  which  the 
first  symptom  was  frequency  of  urination,  and  in  48  cases  difficulty  of 
urination  was  also  present.  In  4  cases  the  onset  was  ushered  in  with 
hematuria,  and  in  4  with  complete  retention  of  urine. 

Pain  was  not  infrequently  an  initial  symptom,  and  its  location  in 
these  cases  has  been  tabulated  as  follows: 

Cases. 

Urinary  tract  (bladder  or  urethra) 16 

Rectoperineal  region 7 

Inguinal  and  scrotal  regions 2 

Dorsal,  sacral  or  gluteal  regions 6 

Lower  extremities 3 

Hypogastriuni      .,..-.,.,,,...,".,.  1 


670  CANCER  OF  THE  PROSTATE 

In  most  of  the  cases  in  the  above  tabulation  the  pain  was  generally 
quite  marked  and  sometimes  very  severe.  Those  cases  in  which  only 
very  slight  burning  was  complained  of  were  not  included,  though  several 
cases  in  which  the  burning  was  severe  and  amounted  to  a  pain  have 
been  included.  There  was  one  patient  in  which  irritability  in  the 
bladder  was  quite  marked.  One  patient,  aged  sixty-four  years,  was 
suddenly  seized,  during  urination,  with  an  excruciating  pain  which 
radiated  from  the  bladder  to  the  end  of  the  penis,  and  after  that  re- 
curred frequently.  In  another  case  the  onset  symptom  was  pain  in  one 
groin  and  down  the  back  of  the  thigh,  which  his  physician  told  him  was 
rheumatic  in  character,  and  gave  him  "appropriate"  treatment  for 
seven  months,  when,  for  the  first  time,  a  very  slight  difficulty  of  urina- 
tion was  noticed.  Only  four  weeks  before  admission  were  his  urinary 
symptoms  sufficient  to  call  attention  to  his  prostate,  by  which  time  the 
entire  prostate  and  seminal  vesicles  were  involved  in  an  extensive  car- 
cinomatous  growth.  In  another  case  the  first  symptom,  which  came 
on  suddenly  two  and  a  half  years  before  admission,  was  a  severe  pain 
in  the  rectum  which  became  continuous  and  grew  steadily  worse. 
Another  patient  had  had  only  one  symptom  since  the  beginning,  three 
months  before,  sharp,  shooting  pains  in  the  left  hip  radiating  down  the 
left  thigh  to  the  knee  and  associated  with  numbness  which  extended  to 
the  foot.  There  was  practically  no  urinary  disturbance,  although  the 
membranous  urethra,  prostate,  seminal  vesicles,  pelvic  glands,  and 
rectum  were  involved  in  an  extensive  carcinomatous  mass. 

In  145  cases  of  benign  hypertrophy  the  onset  symptoms  were  as 
follows: 

Cases. 

Frequency  of  urination 88 

Difficulty  of  urination 78 

Pain 25 

Hematuria 7 

Complete  retention  of  urine 8 

Incontinence  of  urine 8 

In  12  of  the  25  cases  of  benign  hypertrophy  in  which  pain  was  present 
there  was  only  a  slight  burning  in  the  urethra,  and  in  3  the  pain  was 
merely  the  discomfort  produced  by  straining  to  void.  In  1  case  there 
was  sharp  pain  which  followed  sudden  stoppage  of  urine  during  micturi- 
tion. In  9  cases  calculi  were  present.  In  no  case  were  there  the 
symptoms  of  sciatica  or  severe  pain  in  the  hips,  buttocks,  thighs,  or 
groins  which  have  been  seen  in  many  of  our  cases  of  carcinoma. 

Hematuria  is  shown  to  have  been  a  more  common  initial  symptom  in 
benign  hypertrophy  than  in  carcinoma. 

In  conclusion  it  may  be  remarked  that  in  the  majority  of  cases  the 
onset  is  much  the  same  as  that  of  benign  hypertrophy;  an  increase  in 
the  frequency  and  difficulty  of  urination,  which  is  often  slowly  pro- 
gressive in  character.  Pain  alone  is  a  much  more  common  symptom, 
and  frequently  remains  for  a  long  time  the  only  symptom.  In  one 
remarkable  case  the  first  and  only  symptom  complained  of  was  pain  in 
the  legs. 


DURATION  AND  COURSE  OF  DISEASE  671 

In  60  cases  which  were  studied  by  Motz  the  initial  symptom  was: 
difficulty  of  urination  in  38  cases;  complete  retention  of  urine  in  8 
cases;  hematuria  in  8  cases;  neuralgia  in  5  cases. 

Duration  and  Course  of  Disease. — Guyon  recognized  three  forms:  (1) 
those  with  a  rapid  course,  in  which  the  symptoms  may  have  been 
present  a  very  short  time;  (2)  those  following  a  subacute  course,  the 
disease  having  been  present  after  the  tenth  or  twelfth  month;  and  (3) 
those  following  a  very  slow  course  with  a  duration  of  two  or  three 
and  even  as  long  as  nine  years.  In  26  carefully  studied  cases  Motz 
found  that  40  per  cent,  of  the  patients  died  within  seven  months 
after  the  initial  symptoms,  7  lived  over  a  year,  and  6  for  periods 
varying  from  two  to  ten  years.  In  making  this  study  we  have  pre- 
pared a  table  which  shows  the  duration  of  various  symptoms  in  our 
cases. 

DUBATION  OF  VARIOUS  SYMPTOMS  AT  TIME  OF  ADMISSION  OF  PATIENT. 

.i  .JL  >>  g    .          -=  i  J. 

:    I    I    II   !     t     ,l.i 

3  fci  C  jf  oi  c  M 

•^  ??  'C  fa,  „:  O  o 

§4        a  a        c   .        c  S.        M-|        "'-5          ~ 

3.2          .2       -9 "          .3-         .S  .-         -- 


13  9  4 

2 
3  3  2 

1  2 

2  1  2 
1 

1 
1 

As  shown  in  the  above  tabulation  symptoms  were  present  in  many 
cases  for  prolonged  periods,  the  longest  being  twenty  years,  during  which 
the  patient  had  difficulty  of  urination  and  more  or  less  frequent  cathe- 
terization.  There  were  5  cases  in  which  symptoms  had  been  present 
more  than  ten  years.  None  of  these  cases,  however,  were  subjected  to 
prostatectomy,  and  we  cannot  therefore  say  with  positiveness  that  the 
early  symptoms  were  not  due  to  benign  obstruction  to  urination.  In 
23  operated  cases  in  which  there  was  no  hypertrophy,  the  entire  pros- 
tate being  carcinomatous,  there  was  one  in  which  difficulty  and  fre- 
quency of  urination  had  been  present  for  six  years  and  severe  pain  for 
five  years,  and  other  cases  in  which  frequency  and  difficulty  had  been 
present  for  three  years  in  1  case,  two  years  in  2  cases,  one  year  in  3 
cases,  and  six  months  in  1  case.  These  statistics  are  sufficient  to 
show  that  the  course  of  the  disease  is  very  variable  in  its  duration, . 
some  cases  being  extremely  rapid  and  ending  in  death  in  less  than  a 
year;  but  in  the  majority  is  of  two  or  three  years'  duration,  many 
cases  extending  over  three  or  four  years,  and  a  few  cases  over  five 
years. 

In  the  above  tabulation  it  is  noteworthy  that  pain  came  on  ^much 


Q 

St 

GO 

AH 

• 

PH 

m 

1  to    6  months 

.      .      10 

9 

13 

4 

6  to  11        "           .      .      . 

.      .        4 

5 

4 

i 

1 

12  to  17        "           .      .      . 

.      .      14 

12 

4 

2 

3 

18  to  23                    .      .      . 

.      .        3 

3 

1 

24  to  36       "           .      .      . 

.      .      18 

22 

2 

1 

1 

Over    3  years  . 

3  to      5      "       .      .      .      . 

.      .        4 

9 

2 

6  to    10      "       .      .      .      . 

.      .        6 

7 

2 

1 

Over  10     " 

2 

1 

2 

672  CANCER  OF  THE  PROSTATE 

later  than  urinary  obstruction.  In  only  13  cases  of  the  111  had  pain 
been  present  over  three  years  and  in  the  majority  of  cases  under  eighteen 
months. 

Catheter  Life. — In  21  cases  the  patient  had  complete  retention  of  urine 
and  had  used  a  catheter  regularly  for  varying  periods  up  to  three  years. 
In  13  cases  the  catheter  had  been  used  less  than  six  months,  in  5  cases 
over  a  year,  and  in  2  cases  over  two  years.  In  23  cases,  although  the 
patient  was  able  to  void,  urination  was  so  slow,  difficult,  and  frequent 
that  the  catheter  was  used  one  or  more  times  daily.  In  14  of  these 
cases  this  has  been  present  for  less  than  six  months,  in  3  cases  between 
six  months  and  a  year,  in  2  cases  over  one  year,  in  3  cases  over  two  years, 
and  in  1  case  five  years.  In  8  cases  complete  retention  of  urine  occurred 
occasionally,  requiring  catheterization,  but  these  patients  did  not  use 
the  catheter  every  day. 

When  the  patient  was  admitted  to  the  hospital  the  symptoms  presented 
were  as  follows:  Complete  retention  of  urine  and  catheter  life  19  cases. 
The  number  of  times  daily  in  which  catheterization  was  necessary  was 
as  follows:  Two  times,  2  cases;  three  times,  4  cases;  four  times,  2 
cases;  five  times,  1  case;  six  times,  4  cases;  eight  times,  3  cases;  ten 
times,  2  cases;  twenty  times,  1  case. 

Incomplete  retention  of  urine  but  catheter  used,  22  cases;  once  daily, 
2  cases;  twice  daily,  5  cases;  three  times,  4  cases;  four  times,  5  cases; 
five  times,  3  cases;  six  times,  1  case;  seven  times,  1  case;  every  few 
minutes,  1  case. 

In  those  cases  in  which  urination  was  possible  the  difficulty  of  urina- 
tion was  great  in  28  cases;  moderately  difficult  in  6  cases,  slightly 
difficult  in  5  cases. 

The  frequency  of  urination  was  very  frequent  (every  few  minutes  to 
one  hour)  in  38  cases ;  moderately  frequent  (about  every  two  hours)  in 
7  cases;  slightly  more  frequent  than  normal  in  13  cases.  In  2  cases 
there  was  constant  dribbling  of  urine  associated  with  a  large  amount  of 
residual  urine. 

Pain. — The  location  and  the  severity  of  the  pain  present  on  admission 
is  graphically  shown  in  the  accompanying  table: 

Slight.       Moderate.        Severe. 

Urethra 4  4  10 

Penis 3  4  11 

Perineum 3  5  7 

Bladder 4  2  9 

Rectum 2  0  10 

Groin 1  1  0 

Testicle 3  0  3 

Hip 2  3  4 

Thigh 2  4  8 

Leg 2  8  8 

Foot ' 1  1  3 

Lumbar 5  3  7 

Sacral 2  2  5 

Buttocks 0  4  1 

Pubic 2  3  5 

Renal  colic      .      .  ,000 


LOSS  OF  WEIGHT  673 

.The  regional  pains  above  tabulated  most  frequently  occurred  in 
groups.  Of  these  the  genito-urinary  was  the  most  common,  and  was 
characterized  by  pain  in  the  bladder,  urethra  and  penis,  especially 
during  urination.  The  rectum  and  perineum  were  also  grouped 
together,  the  pain  there  being  generally  due  to  pressure  from  the  enlarge- 
ment of  the  gland,  which  was  often  sufficient  to  greatly  reduce  the  lumen 
of  the  rectum  and  render  defecation  difficult.  The  other  groups  of 
symptoms  may  be  classed  as  referred  rather  than  local.  Among  them 
were  noticed  three  distinct  groups :  Those  radiating  to  the  groin  and 
testicle,  those  radiating  to  the  lower  extremities,  and  those  radiating  to 
the  back,  sides,  and  buttocks.  The  explanation  of  these  pains  is 
probably  the  same  as  in  cases  of  chronic  prostatitis,  a  reference  of  pain- 
ful stimuli  to  other  nerves  running  into  the  same  segment  of  the  cord  as 
the  periprostatic  nerves. 

Hematuria. — Hematuria  was  present  at  one  time  or  another  during 
the  course  of  the  disease  in  16  cases.  In  10  of  these  it  had  been  inter- 
mittent and  only  once  considerable  in  amount.  In  3  cases  the  amount 
of  blood  present  was  moderate  and  in  6  slight.  In  6  cases  blood  was 
continuously  present,  in  1  slight,  in  2  moderate,  and  in  3  considerable  in 
amount.  Examination  of  the  urine  on  admission  showed  blood  in  8 
cases,  and  in  6  of  these  it  was  very  slight  in  amount,  but  in  3  cases  it  was 
quite  considerable. 

Hematuria  seems  to  be  more  suggestive  of  vesical  tumor,  calculus, 
or  a  benign  middle  lobe.  It  is  certainly  not  so  commonly  present  as  in 
cases  of  benign  hypertrophy  of  the  prostate,  as  in  my  series  of  145  cases 
I  found  it  present  in  15  per  cent.  The  absence  of  hematuria  is  due  to 
the  fact  that  carcinoma  of  the  prostate  does  not  invade  the  bladder 
except  in  a  small  proportion  of  cases,  but  is  retrovesical  and  pelvic 
rather  than  intra vesical.  It  is  also  interesting  to  note  that  there  are  no 
cases  in  this  series  in  which  hemorrhage  from  the  penis  occurred, 
although  in  3  cases  the  anterior  urethra  was  surrounded  with  more  or 
less  extensive  carcinomatous  infiltration,  in  1  case  producing  a  con- 
tinuous carcinomatous  priapism. 

Loss  of  Weight. — In  30  cases  consideraole,  in  11  cases  moderate,  in  7 
cases  slight,  and  in  13  cases  no  loss  of  weight  was  recorded.  In  28  cases 
no  mention  was  made  on  this  point.  Although  in  the  later  stages  of  the 
disease  the  emaciation  was  profound  and  rapid,  I  have  seen  a  great 
many  cases  with  very  extensive  and  long-standing  carcinoma  which 
were  not  associated  with  any  loss  of  weight,  and  the  patient  remained 
markedly  active  and  strong. 

The  following  table  shows  the  condition  of  the  sexual  powers  in  47 
cases  present  on  admission  as  given  by  patients  in  cases  in  which  a 
record  had  been  made : 

SEXUAL  POWEKS. 

Coitus          Coitus       Coitus  not        Coitus 
impaired,   attempted,   impossible. 

. .  2 

4  3  1 

4  24 


Erections. 

nornr 
.       .       .       .      8 

.       .       .       .      1 

M  u     I  —  43 

674  CANCER  OF  THE  PROSTATE 

While  it  is  true  that  carcinoma  has  a  much  more  decided  effect  uppn 
the  sexual  powers  than  hypertrophy  of  the  prostate,  as  shown  by  the 
above  table,  it  is  also  true  that  in  cases  of  extensive  involvement  of  the 
prostate  and  seminal  vesicles  there  may  be  no  impairment  of  the  sexual 
powers.  One  patient,  upon  whom  a  radical  operation  was  performed, 
stated  on  admission  that  erections  were  normal,  coitus  normal  and 
indulged  in  about  three  times  a  week,  and  that  ejaculation,  though  not 
quite  so  free  as  formerly,  was  not  accompanied  by  pain.  In  this  case 
the  entire  prostate  was  carcinomatous  and  both  seminal  vesicles  and 
vasa  deferentia  were  filled  with  carcinomatous  cells.  In  another  case  in 
which  symptoms  of  urinary  obstruction  had  been  present  for  four  years, 
in  which  the  seminal  vesicles  and  prostate  were  extensively  involved 
and  the  radical  operation  was  performed,  microscopic  examination 
showed  both  vasa  deferentia  and  seminal  vesicles  completely  filled  with 
carcinoma  cells,  the  patient  reported  that  intercourse  was  entirely 
satisfactory.  In  some  cases  the  only  complaint  is  that  the  amount  of 
semen  ejaculated  was  less  than  normal. 

Duration. — As  shown  in  the  statistics  given  above,  cancer  of  the 
prostate  (even  when  unaccompanied  by  hypertrophy)  may  be  of  slow 
growth  and  remain  for  a  long  period  well  confined  within  the  capsule  of 
the  prostate.  Several  years  may  undoubtedly  elapse  before  peri- 
prostatic  structures,  seminal  vesicles,  and  trigone  are  much  invaded,  so 
that  the  chances  for  radical  excision  are  often  excellent. 

Physical  Signs. — We  have  already  recorded  our  findings  in  the  early 
cases.  Briefly  stated,  induration  is  the  most  important  diagnostic  sign 
and  should  lead  to  suspicion  if  only  a  small  area  of  the  prostate  is 
involved.  This  induration  is  generally  very  marked  and  often  almost 
stony.  In  our  earliest  cases  the  area  was  so  minute  that  it  was  not 
recognized  clinically,  but  in  all  these  cases  the  region  involved  was  near 
the  posterior  capsule.  In  a  few  instances  a  smooth,  rounded,  very  hard 
area  in  an  otherwise  soft  prostate  was  present  and  proved  to  be  car- 
cinoma, and  in  other  cases  one-half  was  indurated  and  sharply  demar- 
cated from  the  rest  of  the  prostate.  As  a  rule,  however,  the  whole 
posterior  surface  presented  a  very  hard  surface  which  was  often  smooth 
and  well  defined  laterally.  In  many  cases  there  was  a  slight  roughness, 
and  in  a  few  early  and  most  late  ones  a  markedly  nodular  condition. 

This  diagnostic  induration  is  generally  harder  than  in  prostatitis  or 
tuberculosis  of  the  prostate,  and  the  suburethral  portion  is  more  uni- 
formly involved.  In  some  cases,  especially  where  prostatitis  has  also 
been  present,  diagnosis  is  very  difficult,  and  an  exploratory  perineal 
operation,  at  which  sections  of  the  subcapsular  indurated  areas  may  be 
necessary  before  diagnosis  can  be  made,  should  be  done. 

The  progress  of  the  cancerous  invasion  is  usually  into  the  tissues 
between  the  seminal  vesicles  and  the  bladder  and  characterized  by 
an  induration  which  is  usually  more  marked  than  in  seminal  vesiculitis. 
Sometimes  the  seminal  vesicles  are  not  in  themselves  invaded  and  can 
be  palpated  as  soft  distended  sacs  behind  the  indurated  area  beneath 
the  trigone. 


RECTAL  EXAMINATION  675 

A  transverse  plateau  of  induration  above  and  continuous  with  the 
prostate,  and  involving  the  region  of  both  seminal  vesicles,  the  inter- 
vesicular,  and  subtrigonal  tissues,  is  often  encountered.  If  this  has  not 
progressed  too  far  above  the  prostate  the  case  may  still  be  radically 
operable.  But  usually  it  is  much  too  far  advanced. 

Enlarged  glands  which  are  rarely  found  except  late  are  of  little 
diagnostic  value — when  present  the  malignant  nature  is  evidenced  by 
the  character  of  the  prostate  itself  and  the  glands  are  usually  so  far  out 
along  the  pelvic  wall  that  hope  of  radical  cure  is  gone. 

In  a  series  of  1 1 1  cases  enlarged  glands  were  found  by  rectal  examina- 
tion adjacent  to  the  prostate  in  3,  near  the  seminal  vesicles  in  4,  along 
the  lateral  wall  of  the  pelvis  in  13,  and  in  the  sacral  fossa  in  6  cases.  In 
22  cases  enlarged  glands  of  the  groin  were  found  and  in  2  cases  in  the 
iliac  fossa. 

When  we  consider  the  very  extensive  enlargement  of  the  prostate  and 
seminal  vesicles  which  was  present  in  these  cases  it  seems  remarkable 
that  the  lymph  glands  were  so  seldom  involved,  but  our  findings 
correspond  to  those  of  Kaufmann,  who  discovered  in  100  autopsies  upon 
patients  dying  of  carcinoma  of  the  prostate  only  27  cases  in  which  there 
was  involvement  of  the  pelvic  lymph  glands.  It  shows  the  fact  that 
one  should  not  expect  enlarged  glands  before  making  a  diagnosis  of 
carcinoma  of  the  prostate. 

Rectal  Examination. — The  condition  of  the  prostate,  etc.,  at  examina- 
tion, is  shown  thus: 

Membran- 

Seminal  vesicles.  Intcrvesic-         cms 

Prostate.        Both.         Right.       Left,     ular  space.      urethra. 

Size: 

Slight  enlargement    ...  16                8                3                2              10                2 

Moderate 27             19               3               3             16               8 

Considerable 64             39               2               3             37             24 

Indefinitely  described  4 

Surface: 

Smooth      ......  32               7               1               1               5 

Rough 69             30               3               3             25               6 

Not  noted 10      ... 

Consistency: 

Soft 2 

Elastic 1              14               3               5               7             11 

Slightly  indurated 2                2                1                3 

Moderately  indurated     .      .  6                3                7                4                2              24 

Very  hard 78             56                2                2             49             26 

Stony 9               9              . .              . .              10               5 

Mixed,  soft  and  hard  10 

Consistence. — In  the  above  tabulation  of  the  prostatic  findings  the 
one  thing  that  stands  out  prominently  is  the  induration.  Whereas  the 
large  majority  of  benign  prostatic  hypertrophies  are  elastic  or  even  soft, 
there  is  only  1  case  of  cancer  which  was  described  as  elastic,  and  none 
were  entirely  soft  (barring  2  cases  spoken  of  below). 

In  our  series  of  145  cases  of  benign  hypertrophy  the  prostate  was 
described  as  soft  in  56,  firm  in  45,  moderately  hard  in  14,  very  hard  in 
none,  stony  in  none.  The  marked  contrast  is  at  once  apparent,  and  it  is 
only  necessary,  therefore,  to  say  that  whenever  the  prostate  or  only  a 
portion  of  it  is  quite  hard  it  should  be  viewed  with  suspicion. 


676  CANCER  OF  THE  PROSTATE 

The  case  in  which  the  prostate  was  everywhere  elastic  was  one  in 
which  the  lateral  and  median  lobes  were  considerably  enlarged  by 
benign  hypertrophy  and  the  carcinoma  was  confined  to  a  small  area 
(about  1  cm.  in  diameter)  in  the  anterior  commissure,  which  could  not 
be  palpated  by  rectum.  In  2  cases  the  seminal  vesicles  were  very 
hard  and  evidently  markedly  involved  by  cancer,  but  in  the  region  of 
the  prostate  there  was  a  very  prominent,  smooth,  soft,  almost  fluctuat- 
ing mass,  oval  in  shape,  and  evidently  hematoma  or  blood  cyst  beneath 
the  posterior  capsule.  In  neither  of  these  cases  was  operation  per- 
formed; but  in  another  case  in  which  a  perineal  prostatectomy  was 
done  a  cyst  1  x  1.5  cm.  in  size,  filled  with  brownish  fluid,  was  found  just 
beneath  the  capsule  next  to  the  cancer,  and  was,  I  believe,  the  same 
process  (old  hematoma)  but  of  a  smaller  size. 

It  is  the  group  of  10  cases  described  above  as  mixed,  soft,  and  hard 
that  are  the  most  interesting,  as  it  contains  many  in  which  the  diagnosis 
was  extremely  difficult,  and  often  not  made  except  on  the  operating 
table  and  with  the  aid  of  stained  frozen  sections.  In  all  but  2  of  these 
10  cases  perineal  operations  were  performed  (radical  2,  conservative  6), 
and  the  tissues  have  been  carefully  examined.  In  6  of  these  benign 
hypertrophy  was  present  along  with  cancer.  In  2  of  these  one  lobe  of 
the  prostate  was  soft  and  showed  only  a  benign  hypertrophy,  but  on  the 
other  side,  which  was  hard,  there  was  a  layer  of  carcinoma  between 
the  capsule  and  the  hypertrophied  lateral  lobe.  In  3  cases  the  sub- 
capsular  "shell"  of  carcinoma  was  present  also  on  the  soft  side,  but  was 
thin  enough  to  transmit  the  elasticity  of  the  hypertrophied  lobe  beneath. 

In  1  case  only  one  nodule  of  cancer  (about  1  cm.  in  diameter)  was 
found  beneath  the  capsule  on  the  left  side.  The  rest  of  the  prostate 
was  composed  of  benign  adenomatous  spheroids. 

In  2  cases  in  which  the  radical  operation  was  done  no  benign  ade- 
nomatous hypertrophy  was  present,  the  entire  prostate  being  replaced 
by  cancer.  In  both  of  these  cases  it  is  difficult  to  explain  the  compara- 
tive softness  of  one  of  the  lobes  which  was  noted  on  several  careful 
examinations. 

A  review  of  these  10  cases  seems  to  show  that  the  coexistence  of 
benign  adenomatous  hypertrophy  may  lead  to  a  modification  of  the 
induration  usually  found  in  cancer  of  the  prostate  when  the  layer  of  the 
cancer  between  the  posterior  capsule  and  hypertrophied  area  is  not  too 
thick  to  transmit  the  elasticity  of  the  hypertrophied  lobe  beneath, 
When  no  hypertrophy  is  present  the  prostate  is  almost  always  very 
hard  in  those  portions  of  the  prostate  involved  by  cancer. 

The  induration  usually  found  in  carcinoma  of  the  prostate  is  of  a 
peculiar  incompressible  character,  entirely  different  from  that  seen  in 
tuberculosis  and  chronic  prostatitis,  and,  as  shown  above,  usually  not 
associated  with  any  areas  of  softness  unless  a  portion  of  the  prostate  be 
still  uninvaded  or  unless  there  be  an  elastic  hypertrophied  lobe  beyond 
a  thin  shell  of  carcinoma.  When  the  entire  prostate  has  become 
involved  the  diagnosis  is  at  once  apparent.  The  prostate  is  usually 
more  firmly  fixed  in  its  location  by  pericapsular  adhesions  (due  to 
inflammatory  infiltration  as  is  often  seen  adjacent  to  carcinoma  and  not 


RECTAL  EXAMINATION  677 

necessarily  cancerous  invasion) .  Where  only  a  portion  of  the  prostate 
is  involved,  and  especially  when  coexistent  with  hypertrophied  lobules, 
the  diagnosis  is  often  very  difficult,  and  in  fact  impossible;  but  the 
presence  of  such  an  area  of  induration  should  lead  to  a  suspicion  of 
carcinoma,  and  careful  investigation  at  operation  with  incision  of  the 
suspected  area  (if  necessary)  and  perhaps  stained  frozen  sections.  In 
such  cases  the  consent  of  the  patient  to  a  radical  operation,  in  case  the 
disease  should  prove  carcinomatous,  should  be  obtained  beforehand. 
As  noted  above  the  enlargement  was  slight  in  16,  moderate  in  27,  and 
considerable  in  64  cases.  As  a  rule,  when  the  carcinoma  has  not  spread 
beyond  the  prostate  there  is  only  a  moderate  amount  of  enlargement 
present,  and  often  the  prostate  is  only  very  slightly  enlarged.  In  most 
of  our  early  cases  this  was  the  condition  present,  and  not  infrequently, 
owing  to  the  small  size,  their  physicians  were  apt  to  consider  the  pros- 
tate negative  on  rectal  examination  even  when  the  disease  had  spread 
to  the  space  between  the  seminal  vesicles  and  bladder.  The  line  of 
demarcation  between  the  prostate  and  the  extensive  transverse  plateau 
of  induration  above  it  is  often  impossible  to  outline,  and  not  infre- 
quently the  prostate  is  described  as  considerably  larger  than  normal, 
and  at  operation  the  enucleated  lateral  lobes  are  found  to  be  very  little 
enlarged. 

The  surface  of  the  prostate,  as  indicated  above,  was  smooth  in  32 
and  rough  in  69  cases.  Under  the  head  of  rough  we  have  included  cases 
described  as  irregular,  with  a  nodule  here  and  there,  as  well  as  those  in 
which  marked  roughness  was  everywhere  present.  One  of  the  most 
surprising  findings  has  been  that  the  surface  is  remarkably  smooth  in 
many  cases.  This  is  due  to  the  fact  that  the  fascia  of  Denonvilliers, 
which  extends  from  the  triangular  ligament  upward  beyond  the  seminal 
vesicles  as  a  tense  fascia  closely  applied  to  the  posterior  surface  of  the 
prostate  in  the  anterior  of  its  two  layers,  makes  a  firm  barrier  against 
invasion  toward  the  rectum.  In  fact,  this  fascia  remains  itself  free 
from  invasion  generally  until  late  in  the  disease,  but  although  many  of 
the  cases  are  perfectly  smooth,  when  roughness  is  present,  it  is  usually 
so  entirely  different  from  anything  seen  in  hypertrophy  of  the  prostate 
that  carcinoma  should  at  once  be  suspected. 

In  our  series  of  145  cases  of  benign  hypertrophy  there  was  only  1 
case  which  was  rough  and  nodular,  and  in  14  cases  in  which  the  smooth- 
ness of  the  posterior  surface  was  distorted  by  the  presence  of  one  or  more 
lobules  which  projected  beyond  the  confines  of  the  rest  of  the  hyper- 
trophied prostate,  in  some  cases  having  broken  through  the  posterior 
capsule,  generally  at  the  upper  end  on  one  or  both  sides,  and  thus  pro- 
jecting into  the  region  of  the  seminal  vesicles,  and  occasionally  toward 
the  apex  of  the  prostate,  where  the  lobule  sometimes  encroached  upon 
the  rectum.  In  these  cases,  however,  the  lobule  was  smooth  and  gen- 
erally somewhat  elastic,  and  entirely  different  in  its  appearance  from 
the  indurated  areas  seen  in  our  cases  of  early  carcinoma.  In  some  cases 
of  benign  hypertrophy  with  a  history  of  suppurative  conditions,  ad- 
hesions, and  irregular  areas  of  infiltration  suggested  carcinoma  strongly, 
and  in  one  such  case  the  diagnosis  of  carcinoma  was  held  until  after  a 


678  CANCER  OF  THE  PROSTATE 

suprapubic  drainage  the  prostatitis  disappeared,  and  along  with  it  the 
posterior  surface  of  the  prostate  became  smooth  and  elastic,  so  that  the 
benign  character  of  the  enlargement  was  at  once  evident  and  demon- 
strated by  perineal  prostatectomy. 

Seminal  Vesicles. — As  shown  in  the  above  tabulation  the  seminal 
vesicles  were  frequently  involved.  The  seminal  vesicles,  one  or  both, 
were  indurated  in  88  cases  and  more  or  less  enlarged  in  82  cases.  It  is 
probable  that  both  of  these  figures  should  be  a  little  larger,  as  the  semi- 
nal vesicles  were  in  some  cases  difficult  to  reach,  owing  to  the  thickness 
of  the  perineum,  the  fatness  of  the  patient  or  the  large  size  of  the  pros- 
tate. Only  14  cases  are  recorded  in  which  both  seminal  vesicles  were 
normal  in  consistence  and  size,  and  therefore  probably  not  involved  by 
the  carcinoma.  These  14  cases  are  of  considerable  interest.  In  all  but 
2  cases  the  diagnosis  of  carcinoma  was  confirmed  by  study  of  tissues 
removed  at  operation  (radical  excision  3,  perineal  prostatectomy  9). 
In  2  of  the  cases,  in  which  the  radical  operation  was  performed,  although 
the  seminal  vesicles  were  free  from  invasion,  there  was  a  small  area  of 
carcinoma  just  above  the  prostate,  beneath  the  anterior  part  of  the 
trigone  and  adjacent  to  the  lower  end  of  the  seminal  vesicles.  In  the 
other  case  the  disease  had  not  spread  beyond  the  upper  limit  of  the 
prostate.  In  all  3  of  these  cases  the  diagnosis  was  made  before  opera- 
tion. In  2  cases  (seen  in  1901  and  1903)  the  malignant  nature  of  the 
disease  was  not  recognized  either  before  or  during  the  operation  (1 
suprapubic  and  1  perineal  prostatectomy),  but  the  microscope  sub- 
sequently showed  carcinoma.  In  both  of  these  cases  the  disease  had 
not  spread  above  the  prostate,  and  a  radical  operation  should  have 
given  good  results. 

As  noted  in  the  above  table  there  were  18  cases  in  which  only  one  of 
the  seminal  vesicles  was  found  to  be  involved,  and  in  view  of  the  cases  of 
apparent  cure,  detailed  above,  it  would  seem  probable  that  in  several 
of  these  cases  the  upper  portion  of  the  vesicle  was  free  from  disease  and 
that  a  radical  operation  might  have  been  performed  with  success. 

Intervesicular  Space. — As  noted  in  the  above  table  the  space  between 
the  seminal  vesicles  above  the  prostate  was  involved  in  a  great  many 
cases,  and  had  careful  notes  in  regard  to  this  region  been  made  in  some 
of  the  cases  seen  several  years  ago,  it  is  probable  that  the  percentage  of 
involvements  of  this  region  would  be  even  greater  than  that  of  the  sem- 
inal vesicles.  As  a  rule,  when  the  disease  spreads  above  the  prostate  it 
invades  the  soft  tissues  beneath  the  trigone  adjacent  to  the  ejaculatory 
ducts,  the  lower  ends  of  the  vasa  deferentia  and  seminal  vesicles  usually 
forming  a  small  plateau  of  induration  which,  in  some  cases,  occupies  a 
breadth  of  1  cm.  on  each  side  of  the  median  line.  In  other  cases  it 
extends  to  the  outer  side  of  each  vesicle,  thus  forming  a  plateau  con- 
tinuous with  the  prostate,  and  often  difficult  to  distinguish  from  it. 
Further  progress  generally  consists  of  involvement  of  the  interior  of 
one  or  both  seminal  vesicles  and  tissues  between  them  and  the  bladder, 
thus  forming  usually  a  bicornate  mass  of  induration  with  a  sharp  con- 
cave upper  border  (determined  by  the  lower  limit  of  Douglas's  pouch  of 
peritoneum) .  The  posterior  surface  of  these  supraprostatic  invasions  is 


RECTAL  EXAMINATION  679 

usually  smooth  (on  account  of  the  strong  fascia  covering  them),  but  not 
infrequently  they  are  irregular  and  nodular.  The  induration  like  that 
of  the  prostate  is  usually  very  great,  often  of  stony  hardness,  and  the 
whole  mass  is  fixed  by  adhesions  to  the  pelvic  wall.  When  a  portion  or 
all  of  the  seminal  vesicles  escapes  invasion  it  may  form  a  soft,  somewhat 
elastic  layer  between  the  rectum  and  the  subtrigonal  infiltration  and 
lead  to  mistake,  as  in  one  of  my  cases  in  which  the  radical  operation  was 
performed  on  the  assumption  that  the  disease  had  not  progressed  far 
above  the  prostate.  In  this  case,  although  the  upper  portions  of  the 
seminal  vesicles  were  healthy,  the  disease  had  reached  the  peritoneum 
by  traveling  in  the  space  between  them  and  the  bladder.  A  more 
careful  examination,  especially  making  use  of  the  cystoscope  in  the 
bladder  and  the  finger  in  the  rectum,  should  have  demonstrated  this. 

Membranous  Urethra. — The  above  tabulation  also  shows  a  consider- 
able involvement  of  the  membranous  urethra,  and  here  again  the  figures 
are  probably  less  than  the  truth,  because  in  many  of  the  early  cases  the 
records  are  not  complete  in  this  respect.  As  shown  here,  however,  there 
was  more  or  less  thickening  of  the  membranous  urethra  in  32  cases,  and 
in  61  cases  distinct  induration,  often  of  stony  hardness.  In  most  of 
these  cases  the  invasion  was  continuous  with  that  of  the  prostate  and 
simply  surrounded  the  membranous  urethra.  In  no  cases  was  there 
any  evidence  of  ulceration  into  the  membranous  urethra,  which  like  the 
prostatic  urethra  very  seldom  becomes  ulcerated  in  cases  of  carcinoma. 

In  a  few  cases  the  disease  spread  to  the  perineum  from  the  mem- 
branous urethra,  involving  the  fascia  back  of  the  triangular  ligament 
on  one  or  both  sides;  this  was  recorded  in  5  cases.  In  only  3  cases  did 
the  disease  extend  in  front  of  the  triangular  ligament,  and  in  these  the 
corpus  spongiosum  had  become  infiltrated.  In  one  interesting  case  the 
corpora  cavernosa  were  apparently  completely  replaced  by  carcinoma- 
tous  infiltration  which  extended  up  to  the  glans  penis,  thus  producing  a 
constant  erection  of  almost  complete  character  which  was  due  entirely 
to  the  carcinoma.  In  this  case,  as  well  as  the  two  mentioned  above, 
there  was  no  ulceration  of  the  urethra  and  no  hematuria. 

Rectum. — As  remarked  above,  the  two  layers  of  the  aponeurosis  of 
Denonvilliers  act  as  a  powerful  barrier  against  backward  invasion  of 
carcinoma  of  the  prostate,  and  this  is  abundantly  proved  by  the  fact 
that  among  these  111  cases  there  is  only  1  in  which  the  mucous 
membrane  of  the  rectum  was  invaded,  and  13  cases  in  which  the  prostate 
was  adherent  to  the  rectum.  In  many  of  the  later  cases,  however,  the 
adhesions  were  probably  only  of  such  inflammatory  character  as  is  often 
seen  adjacent  to  malignant  growths  and  do  not  necessarily  mean  in- 
vasion. While  the  aponeurosis  of  Denonvilliers  (Fig.  329)  protects  the 
rectum  from  invasion  it  does  not  prevent  constriction  of  its  lumen  either 
by  the  bulk  of  the  carcinomatous  mass  or  by  constriction  in  the  region 
of  the  seminal  vesicles  through  the  development  of  a  ring  of  carcinoma 
around  the  rectum.  This  was  present  in  only  a  few  cases  when  first 
examined ;  but  from  letters  I  have  received  concerning  the  progress  of 
the  disease  I  am  satisfied  that  it  has  occurred  not  infrequently  later  in 
the  disease.  In  fact,  it  forms  one  of  the  most  troublesome  later  com- 


680  CANCER  OF  THE  PROSTATE 

plications,  leading  to  a  partial  or  almost  complete  stricture  of  the 
rectum,  severe  constipation,  and  occasionally  requiring  colostomy. 

The  Bladder. — The  conditions  present  in  the  bladder  have  been 
studied  in  various  ways:  in  49  cases  by  cystoscopy ;  in  6  cases  by  supra- 
pubic  cystotomy;  in  21  cases  by  perineal  prostatectomy,  and  in  12 
cases  by  autopsy.  In  not  all  cases  were  the  notes  full  in  every  respect, 
so  that  the  figures  in  the  tabulation  given  below  are  not  always  complete. 
They  show,  however,  very  forcibly  the  fact  that  intravesical  tumor 
growth  is  extremely  rare  and  only  occurs  very  late  in  the  disease,  and 
then  in  only  a  small  percentage  of  cases,  that  the  trigone  is  often  thick- 
ened, and  that  the  changes  at  the  prostatic  orifice  consist  usually  in 
thickening  or  possibly  slight  rounding  of  the  median  portion.  In  those 
cases  in  which  considerable  enlargement  of  the  lateral  lobes  was  found 
it  was  probably  due,  in  all  cases,  to  a  coexistent  adenomatous  hyper- 
trophy. 

CONDITIONS  WITHIN  THE  BLADDER. 

Suprapubic  opera-  Perineal  operative 
By  cystoscopy.     five  examination,      examination. 


8 

1  6 

2  3 

3 

2  17 

2 

3 

2  17 

2 

2 

3  8 


4  16 

1 


In  the  12  autopsies  of  which  we  have  careful  examinations  there  were 
only  2  in  which  the  disease  had  spread  into  the  bladder  in  the  shape  of 
a  tumor  or  ulcer.  In  both  of  these  cases  suprapubic  cystotomies  had 
been  performed  several  months  before,  and  although  the  base  of  the 
bladder  was  found  invaded  there  was  no  ulceration  or  any  form  of 
intravesical  tumor. 

As  a  result  of  our  clinical  studies  we  feel  justified  in  saying  that  when 
no  hypertrophy  is  present  the  enlargement  of  the  prostate  in  cancer  is 
generally  not  great;  that  the  growth  is  almost  invariably  upward  into 


Median  portion: 

Normal      

.      .      .        1 

Slight  bar        .... 

.      .      .     23 

Considerable  bar 

.      .      .      15 

Rounded  lobe 

.      .      .        5 

Right  lateral: 

Normal      

.      .      .      10 

Slight  

.      .      .     25 

Considerable  .... 

.      .      .       5 

Left  lateral  : 

Normal      

.      .      17 

Slight  

.      .     22 

Considerable  .... 

.      .      .        7 

Trigone: 

Negative  

.      .      .      13 

Thickened       .... 

.      .      .      17 

Ulcerated        .... 

Tumor       

Ureteral  ridges: 

Negative  

.      .      .      20 

Elevated   

.      .      .      15 

Ulcerated        .... 

Tumor       

.      .      .       2 

Rest  of  bladder: 

Negative   

.      .      .     21 

Ulcerated        .... 

.      .      .        1 

Tumor       

.      .      .        1 

TREATMENT  681 

the  space  between  the  seminal  vesicles  and  around  the  vasa  deferentia 
beneath  the  trigone;  that  the  changes  at  the  vesical  orifice  consist 
usually  in  a  thickening  of  the  median  portion  of  the  prostate,  with 
sclerotic  condition  of  the  internal  sphincter  (making  a  urethral  orifice 
which  is  difficult  to  dilate),  and  that  in  some  cases  the  median  portion 
is  in  the  shape  of  a  moderately  thickened  bar,  but  rarely  a  rounded 
intra vesical  lobe;  that  the  trigone  very  frequently  becomes  thickened 
and  sometimes  considerably  elevated  from  infiltration,  but  that  the 
mucous  membrane  everywhere  (bladder  and  urethra)  preserves  its  in- 
tegrity wonderfully;  that  it  rarely  becomes  ulcerated,  and  then  only 
very  late  in  the  disease. 

Stricture  of  the  prostatic  urethra  was  discovered  in  8  cases  and  probably 
existed  in  others.  In  only  1  case  was  it  impermeable  to  filiforms  and 
all  other  instruments.  Most  often  it  was  merely  a  contracture  through 
which  small  straight  instruments  (Nelaton  catheters)  could  be  passed, 
but  impermeable  to  Coude  catheters  and  cystoscopes, 

Suburethral  Thickening. — The  condition  found  between  the  cysto- 
scope  in  the  bladder  and  the  index  finger  in  the  rectum  is  a  very  im- 
portant diagnostic  sign.  An  invasion  of  the  posterior  commissure  of 
the  prostate  leads  to  considerable  thickening  and  induration,  and  when 
examination  is  made  with  the  finger  in  the  rectum  and  cystoscope  in  the 
urethra  an  increase  in  the  thickness  is  made  out  it  is  often  impossible  to 
feel  the  instrument  anywhere  along  the  urethra,  and  particularly  in  the 
region  of  the  median  portion.  If  the  disease  has  progressed  above  the 
upper  end  of  the  prostate,  thus  forming  an  intervesicular  plateau,  it  is 
usually  impossible  to  feel  the  beak  of  the  instrument  in  the  bladder. 
This  condition  is  entirely  different  from  that  found  in  benign  hyper- 
trophy, in  which  it  is  usually  possible  to  palpate  the  shaft  of  the  instru- 
ment through  the  posterior  commissure  (which  is  usually  not  much 
increased  in  size  until  the  median  portion  of  the  prostate  just  beneath 
the  vesical  orifice  is  reached),  and  it  is  very  rare  to  find  even  in  the 
median  portion  a  marked  induration  in  benign  hypertrophy,  and  the 
beak  of  the  instrument  can  generally  be  felt  through  the  bladder  unless 
the  enlargement  of  the  median  portion  is  considerable. 

Treatment. — There  is  such  a  wide  variety  of  opinion  as  to  the  proper 
treatment  of  cancer  of  the  prostate  that  it  seems  necessary  to  furnish 
here  as  complete  a  statistical  study  as  possible.  I  will  first  give  my  own 
experience  and  then  records  from  the  literature.  My  cases  comprise 
the  following : 

Cases. 

I.  Radical  operation 10 

II.  Subtotal,  excision 4 

III.  Conservative  (partial)  perineal  prostatectomy 71 

IV.  Suprapubic  prostatectomy 2 

V.  Bottini  electrocautery  operation 8 

VI.  Castration 2 

VII.  Suprapubic  drainage 12 

VIII.  Perineal  drainage       . ' 2 

IX.  Treated  by  catheterization 39 

X.  No  catheter  or  operative  treatment 29 

Total  cases  studied 179 


682 


CANCER  OF  THE  PROSTATE 


I.  Technic  of  the  Radical  Operation. —  Described  first  in  the  Johns 
Hopkins  Hospital  Bulletin,  October,  1905. 

The  patient  is  placed  in  the  exaggerated  lithotomy  position  and  an 
inverted  U  perineal  incision  made,  as  in  the  operation  for  simple  hyper- 
trophy of  the  prostate,  the  successive  steps  of  which  are  followed  until 
the  tractor  has  been  inserted  through  a  urethrotomy  wound  of  the 


FIG.  334. — Transverse  section  of  membranous  urethra  at  apex  of  prostate. 

membranous  urethra,  and  the  posterior  surface  of  the  prostate  has  been 
exposed,  largely  by  blunt  dissection.  If  there  is  then  any  doubt  in  the 
mind  of  the  operator  as  to  the  malignant  nature  of  the  disease  an  in- 
cision is  made  through  the  capsule  and  a  section  removed  for  examina- 
tion, frozen  sections  being  made  if  necessary  to  establish  the  diagnosis, 
when  either  the  simple  prostatectomy  for  hypertrophy  or  the  radical 


683 


operation  for  cancer  can  be  performed  as  the  case  requires.  In  the  case 
of  cancer  the  next  step  after  exposing  the  posterior  surface  of  the  pros- 
tate is  to  follow  the  fascia  of  Denonvilliers  upward  and  expose  the 
posterior  surface  of  the  seminal  vesicles  as  much  as  possible  by  blunt 
dissection.  It  is  important  here  to  carry  the  dissection  along  the 
lateral  surface  of  the  gland,  hugging  the  capsule,  and  passing  between 
it  and  the  anterolateral  pelvic  fascia  shown  in  Fig.  240.  By  elevating 
this  fascia  carefully  from  the  anterolateral  surfaces  of  the  prostate 
(Fig.  336)  the  nerves,  and  rich  blood  supply  of  this  region  are  avoided 
(Figs.  337  and  338).  Then  the  membranous  urethra  is  divided  in 
front  of  the  tractor,  as  shown  in  Fig.  334.  The  handle  of  the  tractor 
is  then  depressed  markedly  and  the  fascia  elevated,  the  operator  hug- 


FIG.  335. — Transverse   section   of   prostate   and   rectum.      Arrows   indicate   points    of 
beginning  dissection  beneath  anterior  prostatic  fascia. 

ging  the  anterior  surface  of  the  prostate,  efforts  being  previously  made 
to  push  away  the  anterior  plexus  of  veins  by  blunt  dissection.  By  thus 
going  between  the  lateral  periprostatic  fascia  and  the  prostate  it  is 
possible  to  avoid  much  hemorrhage.  Hemorrhage  should  be  controlled 
as  much  as  possible  by  ligatures  and  then  by  gauze  packs,  which 
should  be  held  tightly  against  the  posterior  surface  of  the  pubes  and 
the  triangular  ligament  by  means  of  a  retractor.  The  seminal  vesicles 
should  be  freed  further  (Fig.  335). 

The  prostate  is  drawn  outward  as  far  as  possible,  thus  exposing  the 
anterior  surface  of  the  bladder,  which  should  be  punctured,  as  shown  in 
Fig.  339,  just  above  the  prostatovesical  juncture.  This  wound  is  now 
enlarged  on  each  side  by  scissors,  the  line  of  division  being  close  to  the 
prostatovesical  juncture  (Fig.  340),  until  the  trigone  is  exposed,  as 


684 


CANCER  OF  THE  PROSTATE 


shown  in  Fig.  341.  With  the  scalpel  a  curved  incision  is  made  across 
the  trigone,  thus  leaving  the  upper  angles  of  the  trigone  intact,  and 
being  careful  to  do  no  injury  to  the  ureters.  By  blunt  dissection  the 
bladder  is  pushed  upward  (Figs.  342  and  343)  the  seminal  vesicles  are 
then  exposed,  as  shown  in  Fig.  344,  and  the  vasa  deferentia  picked  up 
with  a  blunt  hook  and  divided  with  scissors  as  high  up  as  possible.  (In 


FIG.  336. — Dissection  to  elevate  lateral  fascia  from  capsule  of  prostate. 

doing  this  it  should  be  remembered  that  the  vasa  deferentia  pass  around 
the  lower  end  of  the  ureters.)  The  deeper  attachments  of  the  seminal 
vesicles  are  then  freed  and  the  mass,  consisting  of  the  prostate,  urethra, 
cuff  of  the  bladder,  seminal  vesicles,  and  about  5  cm.  of  the  vasa 
deferentia,  is  removed  in  one  piece  (Figs.  345  and  346).  Hemorrhage  is 
again  encountered  in  the  last  step  above  described,  owing  to  the  fact 
that  the  prostatic  plexus  of  veins,  which  pass  up  along  each  side  of  the 


TREATMENT 


685 


prostate,  is  closely  attached  to  the  lateral  border  of  the  seminal  vesicle, 
but  this  can  easily  be  controlled  by  ligatures  or  long  clamps.  The  bleed- 
ing which  comes  from  the  vesical  wound  is  easily  controlled  by  the 
subsequent  sutures,  which  are  placed  so  as  to  anastomose  the  bladder 


FIG.  337. — Prostatic  plexus  of  veins,  side  view.     A,  prostate;  B,  bladder. 


(Fig.  347)  with  the  membranous  urethra,  and  completely  close  the  vesical 
wound.  This  is  easily  accomplished,  as  shown  in  Figs.  247  and  248.  As 
seen  here  the  anterior  wall  of  the  bladder  is  drawn  down  and  fastened 


FIG.  338. — Prostatic  plexus  of  veins,  anterior  view. 

to  the  stump  of  the  membranous  urethra  by  means  of  interrupted 
chromicized  catgut  sutures.  After  forming  the  anastomosis  with 
the  urethra  a  considerable  vesical  wound  is  left  posteriorly,  but  it  is 
easily  closed  by  a  continuous  chromicized  catgut  suture  (Fig.  350-). 


686 


CANCER  OF  THE  PROSTATE 


A  retained  rubber  catheter,  which  should  be  inserted  before  the 
vesico-urethral  anastomosis  is  made,  is  fastened  to  the  glans  penis 
with  adhesive  plaster.  After  placing  light  gauze  packing  in  the  depths 
of  the  wound  the  levator  ani  muscles  are  approximated  with  two  or 
three  interrupted  sutures  of  catgut,  so  as  to  protect  the  rectum  against 


FIG.  339. — Incision  into  bladder,  just  above  prostatovesical  juncture. 

pressure  from  gauze  (Fig.  351),  and  the  external  wound  is  almost 
completely  closed  with  interrupted  sutures  of  catgut  (Fig.  352).  In 
some  instances  I  found  it  difficult  to  place  ligatures  around  hemostatic 
clamps  which  were  deeply  placed,  and  have  therefore  not  removed  the 
clamps  but  allowed  them  to  emerge  with  the  gauze  packing  from  the 
anterior  angle  of  the  wound  (they  were  removed  twenty-four  hours 


TREATMENT 


687 


later) .  If  careful  attention  has  been  given  to  the  prevention  of  hemor- 
rhage and  an  infusion  has  been  begun  early  in  the  operation  there 
should  be  little  or  no  shock. 

The  treatment  during  convalescence  is  very  similar  to  that  employed 
after  perineal  prostatectomy,  viz.,  water  in  abundance,  urotropin,  the 
patient  allowed  to  sit  up  as  soon  as  possible,  daily  irrigations  of  the 
bladder  with  small  amounts  of  boracic  acid  solution,  not  more  than  30 
c.c.  being  injected  at  a  time.  The  gauze  packs  are  removed  in  two  or 
three  days  and  the  urethral  catheter  in  a  week,  but  the  silkworm-gut 
sutures  are  allowed  to  loosen  and  no  attempt  is  made  to  extract  them 


FIG.  340. — Tractor  turned  to  facilitate  opening  bladder. 

forcibly  for  about  eighteen  days.  No  difficulty  is  experienced  in  getting 
a  good  approximation  and  wound  healing,  and  little  or  no  stricture 
formation  has  been  encountered  at  the  point  of  vesico-urethral  anas- 
tomosis. Sounding  is  not  necessary.  None  of  my  patients  have  had 
persistent  fistulse. 

Analysis  of  the  Ten  Cases  in  which  the  Radical  Operation  icas  Per- 
formed.— The  ages  of  the  patients  were  seventy,  sixty-four,  sixty-five, 
sixty-four,  seventy-five,  sixty-eight,  sixty-nine,  seventy-seven,  seventy, 
and  fifty-eight  years  respectively,  and  symptoms  had  been  present 
eleven  months,  three  years,  four  years,  one  year,  eight  months,  one  year, 


688 


CANCER  OF  THE  PROSTATE 


FIG.  341. — Bladder  opened.     Dotted  line  shows  site  of  incision  across  trigone,  below 

ureters. 


FIG.  342. — Trigone  divided,  blunt  dissection  of  seminal  vesicles  begun. 


TREATMENT 


eight  months,  two  years,  three  years,  and  two  and  a  half  years  respect- 
ively. Physicians  had  been  consulted  and  treatment  given  eight 
months  before  in  one  case,  and  seven  months  before  in  another.  In 
both  of  these  cases  an  osteopath  was  employed  who  gave  prostatic 


FIG.  343. — Bladder  pushed  upward  by  blunt  dissection. 

massage,  thus  losing  valuable  time.  One  patient  consulted  a  physician 
for  prostatic  trouble  two  and  a  half  years  before.  One  case  was  sub- 
jected to  a  Bottini  operation  six  months  before  admission.  In  all  cases 
sufficient  symptoms  were  present  to  warrant  rectal  examination  by 

M  u    i — 44 


690 


CANCER  OF  THE  PROSTATE 


which  diagnosis  could  have  been  made  long  before  the  patient  applied 
for  treatment  with  us. 

The  initial  symptoms  were  difficulty  and  frequency  of  urination  in  all 
cases  except  Case  I  and  Case  VII,  in  which  the  first  symptom  was  pain 
in  the  urethra.  Four  patients  (Cases  II,  IV,  VI  and  VIII)  had  never 
suffered  any  pain.  In  4  cases  pain  either  local  or  referred  was  a  promi- 
nent symptom.  One  patient  had  pain  only  on  ejaculation,  and  another 
only  slight  pain  in  the  buttocks.  On  admission,  urination  was  extremely 


FIG.  344 — Seminal  vesicles  and  vasa  exposed,  previous  to  division  of  vasa  and  removal 
of  seminal  vesicles  and  prostate. 

frequent  and  difficult  in  5  cases.  In  1  case  a  catheter  was  used  twice 
daily.  In  3  cases  there  was  little  difficulty,  and  in  2  cases  the  patient 
only  got  up  once  at  night  to  urinate,  and  only  2  patients  had  had 
hematuria. 

The  prostate  was  described  as  considerably  enlarged  in  4  cases, 
moderately  in  3  cases,  and  slightly  enlarged  in  3  cases.  There  was 
marked  induration  in  all  cases,  involving  the  whole  prostate  in  4 
cases.  In  Case  IV  the  marked  induration  was  confined  to  half  of  the 
prostate,  the  other  half  being  very  slightly  indurated. 


TREATMENT 


691 


In  3  cases  (Cases  VII,  VIII  and  X)  the  carcinoma  consisted  of  one 
very  hard  circumscribed  mass  or  lobule,  which  in  each  case  projected 


FIG.  345. — Photograph  of  specimen.     Case  I,  posterior  view. 


FIG.  340. — Photograph  of  specimen.     Case  I,  side  view. 


692 


CANCER  OF  THE  PROSTATE 


from  the  general  level  of  the  left  lateral  lobe,  but  was  still  well  encap- 
sulated. The  rest  of  the  prostate  showed  adenomatous  hypertrophy. 
The  seminal  vesicles  were  found  on  rectal  examination  to-be  free  from 
infiltration  or  induration  in  8  cases.  An  area  of  induration  between  the 
seminal  vesicles  was  present  in  4  cases.  The  catheter  showed  400,  300, 
500,  400,  80,  600,  60,  160,  20  and  10  c.c.  residual  urine  respectively. 


FIG.  347. — Showing  condition  after  excision  of  prostate,  trigone  and  vesicles,  and  struc- 
tures to  be  anastomosed,  bladder  and  membranous  urethra. 


The  cystoscope  showed  a  slight  elevation  of  the  median  portion  in  5 
cases,  in  3  cases  a  small,  definitely  rounded  median  lobe  with  a  shallow 
cleft  on  each  side,  and  in  1  case  a  large  median  lobe. 

The  lateral  lobes  were  scarcely  at  all  enlarged  intravesically  in  all 
cases  but  one  in  which  they  were  moderately  enlarged.  There  was 
generally  not  even  a  sulcus  between  them  in  front,  but  in  2  cases  it  was 
shallow.  In  2  cases  enlargement  of  the  anterior  portion  of  the  prostate 
was  present.  The  vesical  mucosa  was  everywhere  intact,  but  the 
cystoscope  showed  in  2  cases  an  elevation  of  the  trigone,  which  involved 
only  the  anterior  portion  in  Case  II.  In  Case  III  the  trigone  was  con- 


TREATMENT  693 

siderably  elevated  and  irregular,  extending  out  on  the  left  side  as  far  as 
the  ureter.     In  8  cases  the  trigone  was  negative. 

At  operation  the  lower  ends  of  both  ureters  were  intentionally  excised 
for  a  short  distance  in  Case  II,  the  operator  thinking  that  the  disease 
had  reached  this  point.  This  was  a  mistake,  as  it  was  afterward  found 
that  the  induration  was  inflammatory  in  character.  In  Case  V  the 
lower  end  of  the  left  ureter  was  involved  and  had  to  be  excised.  This 
patient  died  of  shock,  and  autopsy  showed  that  while  the  seminal 


FIG.  348. — Anastomosis   of  urethra   and   anterior   wall   of   bladder,    with   chromicized 

catgut  tied  outside. 

vesicles  were  free  the  disease  had  travelled  into  the  peritoneal  cavity. 
The  cystoscopic  evidence  of  elevation  of  the  whole  trigone  should 
evidently  militate  against  the  radical  operation,  as  shown  by  this  case. 
In  Case  III  the  lower  end  of  the  left  ureter  was  unintentionally  divided 
with  scissors  in  making  the  division  along  the  left  lateral  wall  of  the 
bladder.  Anastomosis  was  made  high  up  and  no  inconvenience  re- 
sulted (the  patient  living  three  years).  In  9  cases  the  operation  was 
carried  out  with  apparent  success  and  without  shock,  but  a  study  of  the 


604 


CANCER  OF  THE  PROSTATE 


specimen  removed  showed  carcinoma  near  the  upper  limit  in  2  cases 
(Cases  I  and  III).  In  Case  V  (patient  dying  of  shock)  autopsy  showed 
extensive  carcinoma  of  the  peritoneum  and  retroperitoneal  glands, 
although  the  bladder  and  seminal  vesicles  were  free  from  invasion.  In 
Case  I  the  patient  died  nine  months  after  the  operation  as  a  result  of 
traumatism  and  infection,  caused  by  an  attempt  to  remove  a  stone 
adherent  to  a  silk  suture.  Autopsy  showed  a  very  small  area  of  recur- 
rence 1  cm.  in  diameter  back  of  the  bladder.  In  Case  III  the  patient 


FIG.  349. — Anastomosis 


completed;  remainder  of  bladder  opening  being  closed   with 
continuous  chromicized  catgut. 


lived  over  three  years  in  comfort,  but  autopsy  showed  metastases  in 
various  parts  of  the  body,  the  bladder  and  urethra,  however,  being  free 
from  ulceration.  In  Case  II,  in  which  the  patient  died  six  weeks  after 
the  operation  from  ascending  renal  infection,  as  a  result  of  the  intentional 
but  injudicious  division  of  the  two  ureters,  extremely  careful  examina- 
tion of  all  the  pelvic  tissues  at  autopsy  with  numerous  sections  taken  for 
microscopic  study  failed  to  reveal  any  evidence  of  carcinoma,  and  it 
seems  probable  that  the  disease  had  been  completely  eradicated.  Two 


TREATMENT 


695 


patients  have  apparently  been  cured.  One  died  six  and  a  half  years 
after  the  operation  and  the  other  is  well  five  and  a  half  years  after  the 
operation.  In  both  of  these  cases  the  operative  specimens  showed  that 
the  disease  had  not  reached  the  upper  line  of  excision.  Three  patients 
operated  upon  two  years  ago  are  alive  and  apparently  well. 

In  the  first  cases  there  was  incontinence  when  the  patient  was  on  his 
feet,  but  when  in  bed  and  in  a  sitting  posture  there  was  fair  control.  In 
more  recent  operations  control  has  been  much  better,  in  the  ninth  case 


FIG.  350. — Closure  of  bladder  completed — urethral  catheter  drainage. 

hardly  any  incontinence,  and  in  the  tenth  case  no  incontinence  at  all, 
the  patient  voiding  naturally  with  normal  force  only  three  or  four  times 
by  day  and  none  at  night.  This  has  been  accomplished  by  using  great 
care  to  elevate  the  anterior  layer  of  pelvic  fascia,  which  encloses  the 
lateral  and  anterior  aspects  of  the  prostate,  with  the  nerves  and  blood- 
vessels of  that  region.  This  not  only  obviates  hemorrhage  but  pre- 
serves the  vascular  and  nervous  supply  of  the  triangular  ligament 
and  sphincter,  and  thus  prevents  incontinence  and  removes  the  one 
objection  to  the  operation. 


696 


CANCER  OF  THE  PROSTATE 


As  a  result  of  the  experience  gained  in  these  10  cases  it  may  be  said 
that  the  operation  should  not  be  attempted  when  the  infiltration 
extends  more  than  a  short  distance  beneath  the  trigone,  as  determined 
by  the  cystoscopic  examination  with  the  finger  in  the  rectum  and  the 
cystoscope  in  the  urethra ;  nor  where  the  upper  portions  of  both  seminal 
vesicles  are  involved,  nor  where  an  extensive  intervesicular  mass  or  in- 
durated lymphatics  or  glands  or  involvement  of  the  membranous  ure- 
thra or  muscle  of  the  rectum  shows  that  the  disease  is  manifestly  too  far 


FIG.  351. — Levator  ani  muscles  approximated  with  catgut  suture. 

retrovesical  space. 


Gauze  drainage  to 


progressed;  that  the  corners  of  the  trigone  containing  the  ureteral 
papillae  should  be  left  intact  with  sufficient  tissue  below  them  to  ensure 
proper  suture  and  to  leave  their  openings  free  from  constriction,  1  or  2 
cm.  above  the  wound ;  that  the  hemorrhage  should  be  carefully  checked 
(by  hugging  the  capsule,  injury  of  the  periprostatic  plexus  being  largely 
avoided) ;  that  silk  should  never  be  used  but  occasional  stitches  of  silk- 
worm gut  should  be  employed  in  addition  to  catgut  in  making  the 
urethrovesical  anastomosis;  that  when  the  operation  is  attempted  early 


TREATMENT  607 

it  can  be  performed  without  much  danger  or  great  difficulty,  and  with 
excellent  chance  of  cure;  that  only  7  of  the  10  cases  above  recorded 
were  suitable  for  the  radical  operation,  and  that  in  all  of  these  the 
disease  was  apparently  completely  removed.  Only  2  with  definite 
recurrence  have  been  found.  It  seems  probable  that  radical  cures  have 
been  obtained  in  at  least  5  cases. 


FIG.  352. — Skin  closed ;  subcutaneous  catgut  continuous  suture.     Drainage. 

Radical  Cures  by  Partial  Prostatectomies, — Two  cases,  in  which  small 
nodules  of  cancer  were  completely  removed  in  the  course  of  perineal 
prostatectomy  for  supposed  benign  hypertrophy,  have  been  radically 
cured,  and  therefore  deserve  mentioning.  They  are  reported  elsewhere. 

The  literature  on  the  radical  cure  of  cancer  of  the  prostate  has  become 
fairly  voluminous  since  my  first  paper  in  1906.  Interest  has  been 
greatly  increased  by  the  fact  that  this  subject  was  assigned  for  report 
and  discussion  at  the  International  Medical  Congress  in  London,  1913, 
and  at  the  International  Association  of  Urology  in  Berlin  in  1914.  At 
London  reports  of  successful  results  with  the  operation  were  made  by 


698  CANCER  OF  THE  PROSTATE 

Joly,  \Vildbolz,  Legueu,  and  others,  and  at  Berlin  excellent  clinical 
compilations  from  the  literature  were  made  by  Verhoogen,  Schapiro, 
and  Wildbolz.  The  consensus  of  opinion  was  that  for  radical  cure 
radical  excision  was  necessary,  and  that  good  results  could  be  expected 
if  the  operations  were  performed  early. 

II.  Subtotal  radical  excision  of  carcinoma,  with  conservation  of  sphinc- 
ters, and  most  of  the  urethra  and  capsule.    This  operation  has  been 
carried  out  in  4  cases.     The  first  case  showed  a  well-circumscribed  area 
of  carcinoma  in  the  right  half  of  the  prostate.     The  right  lateral  lobe 
lay  in  front  of  this  and  was  an  adenomatous  hypertrophy,  the  left  and 
median  lobes  of  the  prostate  were  also  benign  hypertrophies.     The  area 
was  so  well  circumscribed  that  I  did  not  perform  the  typical  radical 
operation  but  contented  myself  with  removing  the  right  half  of  the 
prostate  with  its  capsule,  the  right  lateral  wall  and  floor  of  the  urethra, 
the  suburethral  tissues  with  ejaculatory  ducts  and  lower  portion  of  the 
right  seminal  vesicle  and  vas  deferens,  all  in  one  piece.     The  left  lateral 
and  median  lobes  were  then  excised  as  usual,  preserving  the  roof,  left 
lateral  wall  of  the  urethra  and  vesical  sphincter. 

The  result  was  splendid.  Perineal  fistula  closed  on  the  ninth  day, 
patient  discharged  on  the  fourteenth  day.  Report  by  letter  five  years 
later:  " Entirely  well ;  urination  normal." 

Two  other  patients  have  been  operated  upon  by  a  similar  technic, 
also  with  excellent  results,  now  four  years  in  1  case,  and  the  method 
can  be  recommended  in  cases  in  which  a  small  nodule  of  carcinoma  well 
circumscribed  and  surrounded  by  healthy  tissue  is  present.  Great  care 
must  be  exercised,  however,  in  choosing  cases,  and  the  radical  operation 
is  generally  the  safer  to  employ. 

III.  Typical  Conservative  (Partial) Prostatectomy. — Seventy-one  cases. 
This  operation  was  done  with  no  idea  of  radical  cure  but  merely  to 
remove  the  obstruction  to  urination.     In  2  cases,  however,  a  small 
nodule  of  carcinoma  was  completely  excised  in  the  removal  of  the  lateral 
lobes. 

In  1  case  the  carcinoma  lay  adjacent  but  not  within  an  adenoma- 
tous lobe,  but  was  radically  removed,  as  shown  by  the  fact  that  the 
patient  is  alive  now,  eleven  years  after  operation. 

The  other  case  was  one  of  obstructive  prostatitis,  the  microscope 
showing  a  small  but  definite  nodule  of  cancer  in  the  tissues  removed 
from  one  lobe.  The  patient  is  alive  and  well  now,  seven  years  after 
operation. 

In  71  cases  conservative  perineal  prostatectomy  was  carried  out  to 
remove  the  obstruction  and  thus  furnish  relief  from  very  difficult  and 
painful  urination  or  a  painful  catheter  life. 

Discovery  of  the  fact  that  a  manifestly  incomplete  operation  of  this 
character  could  give  lasting  functional  results  came  accidentally,  but 
has  now  been  tried  sufficiently  to  make  it  an  operation  of  election  in 
many  cases. 

It  has  indeed  been  surprising  to  find  patients  with  extensive  carci- 
noma of  the  prostate  and  seminal  vesicles  permanently  relieved  of 


TREATMENT  609 

obstruction  to  urination  by  a  simple  shelling  out  of  the  carcinomatous 
tissue  from  the  lateral  and  median  portions  of  the  prostate,  but  such 
is  most  often  the  case. 

The  operation  is  as  follows :  A  description  of  the  principal  steps  in  the 
operation  of  conservative  perineal  prostatectomy  seems  desirable  here, 
as  many  of  the  steps  are  the  same  as  for  the  radical  operation  for  cancer 
of  the  prostate. 

Position  of  the  Patient. — The  exaggerated  dorsal  position  of  the  pa- 
tient is  the  most  satisfactory  and  the  perineal  board  devised  by  Halsted 
is  admirably  suited  for  this  purpose.  The  perineum  should  be  so  ele- 
vated that  it  is  almost  parallel  with  the  floor,  thus  allowing  excellent 
retraction  of  the  rectum  and  splendid  exposure  of  the  posterior  surface 
of  the  prostate.  After  placing  the  patient  upon  the  table,  before  ele- 
vating the  thighs,  a  No.  24  F.  sound  should  be  inserted  into  the  posterior 
urethra,  to  be  used  subsequently  as  a  guide  for  urethrotomy.  If  the 
operator  waits  until  the  patient  is  placed  in  the  urethrotomy  position  he 
will  frequently  find  it  difficult  to  introduce  the  sound  through  the  tri- 
angular ligament. 

Cutaneous  Incision. — The  inverted  U  cutaneous  incision  unquestion- 
ably gives  a  far  better  exposure  than  a  median  incision.  The  apex 
should  be  just  over  the  posterior  part  of  the  bulb,  about  two  inches 
in  front  of  the  anus,  and  the  lateral  branches  directed  outward  and 
backward  parallel  to  the  ischiopubic  ramus,  each  about  two  inches 
in  length.  The  incisions  are  carried  through  the  skin,  fat,  and  super- 
ficial fascia,  and  then  by  blunt  dissection  with  the  handle  of  the 
scalpel  and  the  index  finger  of  the  left  hand  the  space  to  each  side  of 
the  central  tendon  is  opened  up.  In  this  way  it  is  very  simple  to  open 
up  by  blunt  dissection  very  quickly  a  space  on  each  side  reaching  as  far 
as  the  triangular  ligament.  In  so  doing  the  levator  ani  is  pushed  back- 
ward and  outward  on  each  side  and  the  transversus  perinei  muscles  are 
pushed  forward  (Fig.  353). 

Exposure  of  the  Membranous  Urethra. — The  bifid  retractor  is  inserted, 
as  shown  in  Fig.  354.  Traction  upon  this  instrument  gives  an  excellent 
exposure  of  the  narrow  band  of  central  muscle  and  tendon  and  greatly 
facilitates  the  division  close  to  the  bulb  without  injuring  this  hemor- 
rhagic  structure.  After  the  central  tendon  has  been  completely  divided 
and  the  posterior  surface  of  the  bulb  freed  it  is  well  to  insert  a  grooved 
retractor  by  which  the  bulb  and  triangular  ligament  and  external 
sphincter  are  drawn  upward  and  a  better  view  obtained  of  the  recto- 
urethralis  muscle,  which  lies  between  the  two  branches  of  the  levator 
ani  and  covers  the  membranous  urethra,  toward  which  it  draws  the 
anterior  wall  of  the  rectum.  In  dividing  the  recto-urethralis  muscle, 
care  should  be  taken  not  to  injure  the  rectum,  which  is  often  drawn 
forward  so  that  it  lies  almost  in  front  of  the  membranous  urethra.  It 
nearly  always  covers  the  apex  of  the  prostate.  As  soon  as  the  recto- 
urethralis  has  been  thoroughly  divided  it  is  easy,  by  blunt  dissection,  to 
push  the  rectum  backward  and  thus  obtain  a  good  view  of  the  mem- 
branous urethra,  the  bulb  being  drawn  forward  along  with  the  muscular 


700 


CANCER  OF   THE  PROSTATE 


structures  of  the  triangular  ligament.  The  membranous  urethra  is  then 
opened  upon  the  sound  and  the  edges  picked  up  with  artery  clamps, 
being  sure  to  secure  the  mucous  membrane.  A  straight  sound  is  then 
inserted  into  the  bladder  through  the  urethral  wound  (an  assistant  hav- 


FIG.  353. — Opening  up  space  on  each  side  of  central  tendon  for  conservative  or  radical 

operation. 

ing  withdrawn  the  sound  from  the  anterior  urethra),  to  open  up  the  way 
for  the  prostatic  tractor  (Figs.  355  and  356).  In  these  cancerous  cases 
it  may  be  necessary  to  stretch  the  contracted  posterior  urethra  consider- 
ably with  a  glove-stretcher  before  it  is  possible  to  insert  the  tractor 
into  the  bladder  through  the  perinea!  urethrotomy  wound.  Owing  to  the 


TREATMENT 


701 


pronounced  curve  of  this  instrument  (Fig.  355)  it  is  sometimes  difficult 
to  insert.  Sometimes  it  is  well  to  begin  its  introduction  with  the  beak 
turned  backward  and  then  to  rotate  the  instrument  180  degrees  before 
carrying  it  into  the  bladder.  After  the  instrument  has  penetrated  into 
the  prostatic  urethra  it  is  generally  advisable  to  remove  the  anterior 


FIG.  354. — Bifid  retractor  insertec 


Division  of  central  tendon  and  recto-urethralis 
muscle  beneath  it. 


bulb  retractor  and  thus  allow  the  shaft  of  the  tractor  to  be  carried 
farther  forward.  As  a  rule,  little  difficulty  is  experienced  in  inserting 
the  tractor  if  one  has  been  careful  to  secure  the  edges  of  the  mucosa  of 
the  membranous  urethra.  After  reaching  the  bladder  the  blades  of  the 
tractor  are  opened  out  by  means  of  the  external  handles  (Fig.  357),  and 


702  CANCER  OF  THE  PROSTATE 

after  being  fixed  in  this  position  by  means  of  a  set-screw,  traction  is 
made  upon  the  prostate  and  the  farther  separation  of  the  rectum  from 
the  posterior  surface  of  the  prostate  made.  After  dividing  the  recto- 
urethralis  muscle  and  exposing  the  apex  of  the  prostate  one  generally 
finds  it  necessary  to  use  the  knife  to  divide  a  layer  of  fibrous  tissue  which 
lies  behind  the  posterior  surface  of  the  prostate.  After  this  (the 
posterior  layer  of  Denonvilliers's  fascia)  has  been  divided  the  rectum  can 
be  more  easily  pushed  backward,  and  one  enters,  generally  with  ease, 
into  the  space  between  the  two  layers  of  Denonvilliers's  fascia  and  the 
smooth,  glistening  surface  of  the  prostate  is  exposed  (Fig.  358) .  When 
this  layer  is  properly  exposed  no  difficulty  is  generally  experienced  in 
rapidly  freeing  the  entire  posterior  surface  of  the  prostate  and  seminal 


FIG.  355. — Author's  prostatic  tractor  (closed). 

vesicles,  a  good  view  of  which  is  obtained  at  once  by  the  insertion  of 
a  broad  angular  retractor  posteriorly. 

Incision  of  Capsule. — Lateral  retractors  are  so  placed  that  with  the 
posterior  retractor  drawing  the  rectum  backward,  and  the  prostatic 
tractor  drawing  the  gland  outward  a  splendid  exposure  of  the  posterior 
surface  of  the  prostate  is  obtained.  An  incision  is  then  made  through 
the  capsule  on  each  side  of  the  median  line  for  almost  the  entire  length 
of  the  posterior  surface  and  about  1.5  cm.  deep.  These  incisions  are 
about  1.8  cm.  apart  behind  and  1.5  cm.  apart  in  front,  as  shown  in  Fig. 
359.  The  bridge  of  tissue  which  lies  between  them  contains  the  ejacu- 
latory  ducts  and  the  floor  of  the  urethra. 

The  lateral  lobes  are  then  each  completely  removed,  much  of  this 
being  done  by  the  blunt  dissector.  When  the  deep  portion  is  reached— 


TREATMENT 


703 


that  is,  at  the  base  of  the  seminal  vesicle  and  the  bladder — it  is  often 
necessary  to  use  a  sharp  periosteal  elevator  or  a  curette  in  order  to  com- 
pletely remove  all  of  the  carcinomatous  prostatic  tissue  in  that  region. 
The  entire  lateral  mass  of  prostatic  tissue  usually  comes  away  in  one 
piece,  but  in  those  cases  in  which  the  cancer  is  confined  to  the  posterior 


FIG.  350. — Membranous  urethra  opened  on  sound;  edge  caught  with  clips,  tractor  about 

to  be  introduced. 


subcapsular  layer  in  front  of  which  is  a  hypertrophied  adenomatous  lobe 
the  latter  is  usually  separately  enucleated.  After  the  two  lateral  cavi- 
ties are  emptied  the  median  portion  of  the  prostate  is  next  attacked. 
This  is  indicated  in  Fig.  360,  in  which  the  median  portion  is  shown 
diagrammatically,  caught  with  a  sharp  hook.  It  should  be  our  object 
here  to  excise  this  median  suburethral  portion  without  injury  to  the 


704  CANCER  OF  THE  PROSTATE 

ejaculatory  ducts  which  lie  behind  it  (in  order  thus  to  avoid  epididy- 
mitis),  and  with  as  little  injury  to  the  urethra  in  front  of  it  as  possible. 
Remaining  tissue  can  be  removed  with  scissors,  curette,  or  rongeur.  If 
a  rounded  middle  lobe  is  present  it  may  be  drawn  down  and  removed 
through  a  lateral  cavity  (Fig.  361).  It  is  then  advisable  to  remove  the 
tractor  and  dilate  thoroughly  the  external  prostatic  orifice  with  large 
forceps  after  removal  of  the  tractor.  The  finger  is  then  carefully 
inserted  through  the  urethra  and  an  examination  of  the  vesical  neck 
made.  As  a  rule  the  sphincter  will  be  found  tight,  or  often  sclerotic, 
and  thorough  dilatation  should  be  made.  If  there  remains  any  pros- 
tatic tissue  in  the  median  portion  or  elsewhere  around  the  orifice  this 
can  easily  be  enucleated  or  excised,  using  the  finger  as  a  tractor.  In 


FIG.  357. — Prostatic  tractor  opened,  as  in  operation. 

some  cases  the  carcinomatous  infiltration  continuous  with  the  median 
bar  and  extending  beneath  the  trigone  is  felt,  and  it  may  be  advisable  to 
remove  this  more  or  less  completely  (which  can  usually  be  done  with 
ease  with  a  curette  working  upon  the  finger  in  the  bladder  against  the 
trigone  as  a  guide).  Care  should  be  taken  not  to  tear  a  hole  in  the 
urethra  or  bladder,  but  it  is  a  remarkable  fact  that  although  the  urethra 
may  have  been  torn  laterally  or  posteriorly  during  some  of  my  opera- 
tions, and  in  a  few  cases  a  small  portion  excised,  the  healing  in  these 
cases  has  been  entirely  satisfactory  and  there  has  been  no  evidence  of 
intra-urethral  ulceration  or  tumor  outgrowth  through  the  rent.  If  a 
globular  median  lobe  is  present  this  is  usually  easily  enucleable,  as  in 
cases  of  benign  hypertrophy.  The  rest  of  the  operation  is  similar 
to  that  for  benign  cases:  a  large  drainage  tube  through  the  urethra 


TREATMENT 


705 


into  the  bladder,  irrigation  begun  at  once,  the  lateral  cavities 
packed  each  with  strips  of  iodoform  gauze  (Fig.  362),  the  levator  ani 
muscles  drawn  together  in  front  of  the  rectum  with  a  single  suture  of 


FIG.  358. — Prostate  drawn  down  by  tractor,  posterior  surface  freed. 


catgut,  and  the  skin  approximated  on  one  side  by  the  interrupted 
sutures  of  catgut.  If  the  patient  is  very  weak  an  infusion  is  often  begun 
at  the  beginning  of  the  operation,  but  usually  we  wait  until  the  return 
to  the  ward.  From  500  to  800  c.c.  are  generally  given  beneath  the 
M  u  i— .45 


706 


CANCER  OF  THE  PROSTATE 


breasts.  Irrigation,  begun  on  the  operating  table,  is  given  inter- 
mittently in  the  ward.  The  patient  is  given  water  to  drink  as  soon 
as  possible  and  an  effort  is  made  to  make  him  take  as  much  as  he  can. 
The  gauze  is  generally  removed  on  the  morning  after  the  operation, 
and  the  tubes  during  the  afternoon,  when  all  bleeding  following  the 
removal  of  the  gauze  has  ceased.  On  the  following  day  the  patient  is 
usually  put  in  a  wheel-chair  and  taken  outdoors,  and,  as  a  rule,  the 


FIG.  359. — Incision  of  capsule  and  enucleation  erf  lateral  lobes. 

convalescence  is  as  rapid  as  we  see  after  perineal  prostatectomy  for 
benign  hypertrophy.  In  fact,  owing  to  the  small  size  of  the  cavity,  the 
closure  of  the  fistula  and  restoration  of  normal  urination  are  usually 
somewhat  quicker,  as  shown  by  reference  to  the  detailed  report  else- 
where of  cases  treated  by  perineal  prostatectomy. 

Results  of  conservative  perineal  prostatectomy  in  71  consecutive 
cases  of  cancer  of  the  prostate.  There  were  four  deaths,  none  immedi- 
ately following  the  operation,  the  earliest  being  twenty-three  days  after 


TREATMENT 


707 


operation  for  uremia,  and  the  others  twenty-six,  thirty-six,  and  forty- 
nine  days  after  operation.  All  of  these  were  desperate  cases,  suffering 
greatly,  operation  being  performed  in  hope  of  relief,  and  having  little  to 
do  with  the  fatal  ending.  The  mortality  of  5.6  per  cent,  is  therefore  not 
just  to  the  operation.  The  results  obtained  have  been  analyzed  and 
tabulated  as  follows: 


FIG.  360. — Excision  of  infiltrated  median  bar. 


A.  Good  Result  as  Long  as  Patient  Lived,  Twenty-four  Cases. — In  these 
cases  the  operation  was  entirely  successful  in  removing  the  obstruction 
permanently.  The  duration  of  life  was  over  four  years,  1  case;  over 
three  years,  3  cases;  over  two  years,  5  cases;  over  one  year,  4  cases;  six 
to  twelve  months,  5  cases;  under  six  months,  6  cases. 

Many  of  these  cases  were  remarkable  not  only  in  being  completely 
free  from  urinary  obstruction,  but  also  in  being  otherwise  comfortable 
almost  up  to  the  end.  In  4  cases  there  was  some  intestinal  obstruction 
due  to  growth  of  cancer  higher  up.  In  only  3  cases  did  a  small  fistula 


708 


CANCER  OF  THE  PROSTATE 


develop  at  the  site  of  operation  before  death,  but  in  no  case  was  there 
hematuria  at  any  time. 

Twelve  of  the  24  cases  are  reported  to  have  had  no  pain  up  to  death. 
In  7  severe  pain,  generally  in  back  or  thighs,  was  present.  It  was 
present  before  operation  in  most  of  these  cases,  but  there  were  others 
not  in  this  group  in  which  severe  pain  developed  later.  I  think  I  can 
safely  say,  however,  that  it  is  not  hastened  by  operation  and  is  often 


FIG.  361. — Removal  of  rounded  median  lobe  through  the  left  lateral  cavity. 

relieved  thereby.  Fenwick  pointed  out  years  ago  that  in  cancer  of  the 
prostate,  pain  would  often  disappear  when  the  disease  broke  through 
the  capsule — apparently  thus  relieving  tension. 

B.  Patients  Still  Alive  and  Entirely  Relieved  of  Obstruction  to  Urination, 
Fourteen  Cases. — Twelve  of  these  cases  are  free  from  pain.  In  3  a  pin- 
point fistula  exists.  No  hematuria  is  reported,  and  none  have  required 
catheterization,  micturition  being  fairly  normal.  The  duration  since 
operation  is  three  years,  1  case;  over  two  years,  2;  over  one  year,  5; 


TREATMENT 


709 


between  six  and  twelve  months,  2;  indefinite,  2.  If  group  B  be  added 
to  group  A  we  have  38  in  71  cases  with  excellent  operative  result,  or 
53.5  per  cent.  To  this  may  be  added  11  cases  in  which,  although  the 
operative  result,  removal  of  obstruction  and  restoration  of  free  urination 
has  been  accomplished,  still  accompanying  conditions,  present  before 
operation,  have  been  so  severe  as  to  negative  the  results,  e.  g.,  seven 
patients  were  terrible  sufferers  from  pain  (generally  in  back  and  legs) 
before  operation,  and  this  still  continued  in  such  severity  as  to  over- 


FIG.  362. — Lateral   cavities  in  prostate  packed  with  gauze, 
through  membranous  urethra. 


Tube  drain  of  bladder 


shadow  everything  else.  In  2  there  was  very  little  residual  urine 
before  operation,  and  the  size  of  the  bladder  was  small.  Urination  has 
since  been  free  but  frequent.  In  only  1  case  were  there  hemorrhages. 
These  were  all  bad  cases,  3  lived  less  than  one  year,  7  between  one  and 
three  years,  1  still  alive.  They  represent  a  class  of  patients  whose 
sufferings  are  so  intense  from  pain,  and  difficulty  and  frequency  of 
urination  are  so  great,  that  something  is  demanded. 

The  operation,  however,  relieved  the  obstruction  permanently,  and 
these  should  therefore  be  added  to  the  previous  groups,  thus  giving  as 


710  CANCER  OF  THE  PROSTATE 

results  in  removing  obstruction  and  giving  free  urination  49  in  71  cases,  or 
69  per  cent,  successful. 

C.  Partial   Recurrence  of  Obstruction. — There  were  4   cases    (5.6 
per  cent.)  in  which  the  obstruction  relieved  for  a  time  partially  returned 
within  six  months  in  3  cases  and  after  eighteen  months  in  1  case.    The 
latter  patient  lived  over  four  years,  the  others  twenty-two,  ten,  and  four 
months  respectively.    None  of  these  4  patients  returned  to  the  catheter 
life,  and  all  were  undoubtedly  improved  by  operation. 

D.  Complete  Recurrence  of  Obstruction. — This  class  comprises  1 1  cases 
in  which  recurrence  of  obstruction  was  sufficient  to  require  catheteriza- 
tion  in  5  cases  (7  per  cent.),  a  Bottini  operation  in  1  case,  suprapubic 
drainage  in  4  cases  (5.6  per  cent.),  suprapubic  prostatectomy  in  1 
case. 

In  4  of  these  cases  the  obstruction  returned  within  six  months  after 
operation,  in  2  within  a  year,  in  2  over  two  years  later,  in  1  over  three 
years  later.  These  cases  may  therefore  be  set  down  as  failures,  16.6 
per  cent.,  although  a  definite  period  of  freedom  from  obstruction  was 
afforded.  Three  patients  lived  one  year,  5  over  two  years.  In  8  of 
these  11  recurrent  obstruction  cases,  hypertrophy  was  present  (74 
per  cent.),  and  one  patient  was  subsequently  relieved  of  the  obstruction 
by  suprapubic  enucleation  of  two  large  adenomatous  lateral  lobes, 
normal  urination  being  restored.  In  this  case  the  cancer  lay  entirely  in 
the  posterior  part  of  the  prostate  and  seminal  vesicles.  Freyer  has 
reported  similar  cases  in  which  the  demarcation  was  so  sharp  that 
suprapubic  enucleation  could  easily  be  carried  out  successfully. 

The  patients  in  this  group  were  happily  free  from  pain  in  all  but 
2  cases. 

Careful  review  of  the  operative  notes  fails  to  reveal  any  reason  for  the 
recurrence  of  obstruction  in  these  11  cases — apparently  the  removal 
was  just  as  completely  successful  as  in  the  other  cases  which  remained 
free  from  obstruction.  Perhaps  it  is  surprising  that  in  more  cases  this 
frankly  partial  operation  is  not  temporary  in  its  results. 

E.  Complete  Radical  Cures,  Two  Cases. — These  2  cases  were  accidental 
cures.     The  cancer  in  each  case  was  only  a  small  nodule,  not  recognized 
until  after  operation,  but  removed  with  a  sufficiently  wide  margin  of 
healthy  tissue,  so  that  a  complete  cure  has  been  obtained.     Both 
patients  are  alive  and  well  now,  seven  and  a  half  years  in  1  case  and 
eleven  years  in  the  other. 

These  cases  may  be  used  as  an  argument  for  early  perineal 
prostatectomy. 

General  Remarks. — The  foregoing  study  of  71  patients  with  cancer  of 
the  prostate  in  which  69  per  cent,  were  permanently  relieved  of  obstruc- 
tion to  urination  demonstrates  fully,  I  believe,  the  great  value  of 
perineal  prostatectomy,  where  care  is  taken  to  remove  the  cancerous 
lateral  and  median  lobes,  and  any  adenomatous  hypertrophy  which  may 
coexist,  as  it  has  been  shown  to  do  in  61  per  cent,  of  the  cases.  Special 
care  should  be  taken  to  see  that  the  vesical  orifice,  which  is  often  con- 
tracted, is  well  dilated  and  that  no  small  spheroids  of  hypertrophied 


TREATMENT  711 

tissue  remain,  as  these  have  probably  caused  the  recurrence  of  obstruc- 
tion in  several  of  my  cases.  To  recapitulate:  We  have  in  71  cases 
treated  by  conservative  perineal  prostatectomy,  complete  cures,  3  per 
cent.;  permanently  successful  removal  of  obstruction,  69  per  cent.; 
partial  recurrence  of  obstruction,  5.6  per  cent. ;  recurrence  of  complete 
obstruction,  16.6  per  cent.;  deaths  in  hospital,  5.6  per  cent. — the  earli- 
est twenty-three  days — and  no  deaths  strictly  attributable  to  operation. 

IV.  Suprapubic  Prostatectomy,  Two  Cases. — The  prostate  was  enucle- 
ated in  2  cases,  in  both  of  which  the  malignant  nature  of  the  disease  was 
not  recognized.  One  of  these  was  operated  upon  in  1898  by  another  sur- 
geon and  resulted  in  death  thirty  hours  after  the  operation.  Autopsy 
showed  numerous  pelvic  metastases.  In  the  second  case  I  failed  to 
recognize  the  malignant  nature  of  the  disease  and  performed  a  supra- 
pubic  prostatectomy  after  removing  a  very  large  vesical  calculus.  It 
was  impossible  to  separate  the  prostatic  lobes  from  the  urethra,  and  the 
entire  prostate  was  shelled  out  in  one  mass  along  with  the  urethra.  The 
patient  returned  five  years  later  complaining  of  a  tumor  of  the  kidney. 
He  reported  that  there  was  no  difficulty  or  frequency  of  urination  and 
that  the  operation  had  cured  him  completely.  Rectal  examination, 
however,  showed  a  large  indurated  mass  in  the  region  of  the  prostate, 
and  seminal  vesicles,  and  study  of  the  microscopic  sections  of  the 
prostate  removed  at  operation  showed  carcinoma,  thus  explaining  the 
nature  of  the  supposed  kidney  tumor.  The  patient  died  a  few  months 
later.  The  prostatic  enlargement  in  this  case  was  largely  due  to  ade- 
nomatous  hypertrophy.  This  probably  accounts  for  the  ease  with 
which  it  was  shelled  out  suprapubically.  In  cases  in  which  there  is  no 
hypertrophy  present,  but  the  prostate  is  of  the  small,  hard  variety,  as 
seen  in  many  of  our  cases,  it  would  seem  almost  impossible  even  to  start 
the  enucleation  through  the  bladder  and  that  for  such  cases  a  supra- 
pubic  prostatectomy  is  out  of  the  question.  Freyer  agrees  to  this. 
The  fact  that  the  urethra  comes  away  with  the  prostate  in  these  cases  is, 
I  believe,  a  distinct  objection  to  the  suprapubic  route  even  when  the 
presence  of  intra vesical  adenomatous  lobes  makes  it  possible,  as  the 
cavity  may  fill  up  with  a  fungating  carcinomatous  growth. 

It  seems  advisable  here  to  refer  to  recent  papers  by  Freyer  and 
by  Judd. 

In  the  Lancet  for  December  13,  1913,  Freyer  gives  his  statistics  in 
regard  to  cancer.  He  says  he  has  seen  171  cases  of  cancer  to  1105  of 
hypertrophy,  or  13.4  per  cent,  of  all  cases  were  cancer.  He  does  not 
give  the  number  of  these  cancer  cases  which  were  operated  upon,  nor 
has  he  had  complete  pathological  studies  made  of  all  the  prostatectomy 
specimens  to  see  how  many  contain  cancer.  He  details,  however,  10 
cases  in  which  suprapubic  prostatectomy  was  successfully  carried  out, 
the  entire  prostate,  with  the  urethra,  anterior  commissure,  and  "true 
capsule,"  being  removed  in  one  piece.  That  this  procedure  may  be 
radically  successful  in  certain  early  cases  in  which  the  cancer  is  not  too 
close  to  the  capsule,  and  still  confined  within  the  substance  of  the 
prostate,  is  quite  admissible,  and  this  is  borne  out  by  the  fact  that  in 


712  CANCER  OF  THE  PROSTATE 

5  of  Freyer's  10  cases  the  patients  have  been  well  now  from  six  to  ten 
years  since  operation. 

Freyer  does  not  recommend  the  procedure  as  a  radical  operation,  and 
remarks:  "I  could  give  details  of  other  cases  in  which  the  results  were 
not  so  satisfactory,  the  disease  recurring  and  leading  eventually  to 
contraction  of  the  urethra,"  etc. 

One  of  my  cases  (mentioned  above)  operated  as  early  as  1901  and 
published  in  1909  demonstrated  that  it  is  possible  occasionally  to  get  a 
good  functional  result  for  over  five  years — death  finally  supervening 
from  cancer — but  such  are  rare,  and  the  general  consensus  of  opinion  is 
that  cancers  of  the  prostate  should  not  be  attacked  suprapubically. 

In  Judd's  paper  before  the  Southern  Surgical  and  Gynecological 
Association,  1914,  he  reports  among  878  specimens  removed  by  pros- 
tatectomy 93  containing  cancer  were  studied  microscopically.  Seventy- 
five  per  cent,  showed  a  coexistent  hypertrophy,  and  he  confirms  our 
discovery  that  in  such  cases  "  the  malignant  process  always  started  in 
the  posterior  lobe,  and  was  often  distinctly  separated  from  the  rest  of 
the  gland  which  was  not  involved." 

He  has  heard  from  82  of  the  93  patients,  but  gives  no  figures  as  to 
the  number  of  successful  cases,  simply  remarking  that  "  many  of  the 
patients  living  at  the  present  time  are  entirely  free  from  symptoms." 
"  In  the  cases  of  recurrence,  hematuria  was  one  of  the  first  evidences  of 
the  recurrence.  Difficulty  of  urination  was  an  early  symptom  and 
became  rapidly  marked,  necessitating  suprapubic  cystotomy  in  a  num- 
ber of  cases.  Several  lived  three  years  without  trouble,  when  there  was 
a  return  of  all  symptoms."  "  One  patient  living  nine  years  had  a  small 
carcinomatous  nodule  removed."  "Twenty-four  died  within  the  first 
six  months." 

V.  Bottini  Electrocautery  Operation,  Eight  Cases. — The  Bottini  opera- 
tion was  employed  to  relieve  prostatic  obstruction  in  7  cases.  In  4  of 
these  cases  the  diagnosis  of  carcinoma  was  made,  and  the  operation 
employed  simply  as  a  palliative  procedure  with  distinct  improvement 
in  all  4  of  them. 

In  3  cases  the  malignant  nature  of  the  enlargement  was  not  recog- 
nized, and  the  Bottini  operation  was  employed,  as  I  was  using  it  to  the 
exclusion  of  other  methods  at  that  time.  The  results  obtained  were 
very  good  in  all  3  cases.  In  1  case  the  obstruction  recurred,  and  the 
patient  died  within  a  year.  In  the  second  case  the  result  was  excellent 
for  sixteen  months  when  symptoms  of  obstruction  again  appeared,  and 
suprapubic  cystotomy  for  drainage  had  to  be  employed  three  years 
after  the  Bottini  operation.  The  last  case  has  been  remarkable  for  the 
immense  benefit  conferred  by  the  Bottini  operation.  For  almost  six 
years  after  the  Bottini  operation  the  patient  lived  free  from  pain  and 
discomfort,  although  the  prostate  and  seminal  vesicles  were  markedly 
involved,  and  general  glandular  metastases  were  present.  A  review  of 
these  seven  cases  shows  several  remarkably  good  results  with  the 
Bottini  operation,  but,  as  a  whole,  perineal  prostatectomy  is  the  pref- 
erable operation  where  it  is  desired  to  relieve  the  patient  from  the 


TREATMENT  713 

necessity  of  painful  and  difficult  catheterization,  and  the  discomforts  of 
life  with  a  suprapubic  drainage  apparatus. 

VI.  Castration,  Two  Cases. — Castration  was  performed  for  the  relief 
of  prostatic  obstruction  in  2  cases  fifteen  years  ago.     In  1  case  the 
operator  did  not  recognize  that  the  disease  was  carcinomatous,  and  per- 
formed castration,  which  was  then  in  vogue,  in  order  to  produce  an 
atrophy  of  the  enlarged  prostate.     Suprapubic  cystotomy  for  drainage 
was  provided  at  the  same  time.    The  result  was  negative,  and  the 
patient  wore  a  suprapubic  drainage  apparatus  until  his  death  a  year  or 
so  later. 

In  the  second  case,  which  was  operated  by  the  writer,  the  diagnosis 
of  carcinoma  was  evident.  There  was  no  frequency  or  difficulty  of 
urination,  but  the  patient  complained  of  severe  pain  in  the  rectum, 
buttocks  and  limbs.  No  operation  to  relieve  obstruction  was  indicated, 
and  castration  was  performed  with  the  hope  that  some  change  in  the 
prostate,  which  might  bring  about  relief  of  the  rectal  pain,  might  follow. 
The  result,  however,  was  negative. 

VII.  Suprapubic  Drainage,  Twelve  Cases.  —  In  all  these  cases  tne 
catheter  was  tried  first,  and  the  operation  performed  either  because  it 
was  impossible  to  introduce  the  catheter  or  its  use  was  so  painful  or 
difficult  that  catheter  life  could  not  be  endured.  In  several  cases  the 
patient  employed  the  catheter  for  a  long  period  before  finally  demand- 
ing operative  relief.     In  nearly  all  of  these  cases  the  disease  was  far 
advanced  and   the    condition    often    desperate.      One  patient  died 
a  week  after  the  operation,  one  lived  only  a  month,  another  only 
five  months,  and  a  third  six  months.     In  these  3  cases  the  patients 
suffered  very  greatly  and  the  operation  afforded  very  little  relief.     In 
2  cases  it  has  been  impossible  to  find  the  patients  since  their  departure 
from  the  hospital.     In  6  cases  the  drainage  apparatus  was  employed, 
and  in  5  cases  all  reports  state  that  it  worked  well;  there  was  no  leakage 
around  the  tube,  the  patients  were  able  to  empty  the  bladder  at 
fairly  long  intervals  by  opening  the  stop-cock,  and  there  was  very  little 
pain  or  vesical  discomfort. 

As  noted  above,  the  results  obtained  by  suprapubic  drainage  were 
distinctly  better  when  an  apparatus  was  provided  by  which  the  bladder 
would  be  emptied  only  at  stated  intervals  rather  than  being  allowed  to 
drain  continuously. 

VIII.  Perineal  Drainage,  Two  Cases. — In  2  cases  perineal  urethrot- 
omy  had  been  performed,  in  1  case  on  account  of  abscess  of   the 
prostate  involving  the  perineum,  and  in  the  second  case  on  account 
of  the  inability  of  the  patient's  physician  to  pass  a  catheter,  complete 
retention  of  urine  being  present.     Except  in  suppurative  conditions 
perineal  urethrotomy  has  little  to  commend  it. 

IX.  Cases  Treated  by  Catheterization. — There  were  39  cases  in  which 
the  patient  was  advised  to  lead  a  catheter  life  and  no  operation  was 
attempted.     In  nearly  all  these  cases  the  disease  was  too  far  advanced 
for  a  radical  operation,  but  in  many  of  the  cases  conservative  perineal 
prostatectomy  might  have  been  performed  with  considerable  relief.     In 


714  CANCER  OF  THE  PROSTATE 

order  to  compare  the  results  obtained  by  the  use  of  the  catheter  with 
those  of  prostatectomy  we  have  attempted  to  get  an  accurate  idea  of 
the  subsequent  course  of  the  cases. 

It  has  been  impossible  to  get  an  accurate  reply  in  all  cases  as  to  the 
progress  of  catheter  life.  In  2  cases  subsequent  operations  were  re- 
quired. Suprapubic  cystotomy  1,  perineal  prostatectomy  1.  In  10 
cases  the  catheter  life  was  said  to  be  painful,  difficult,  or  very  obnoxious, 
and  often  the  catheter  had  to  be  used  very  frequently.  In  only  8  cases 
was  the  catheter  life  said  to  have  been  satisfactory  and  in  2  of  these  the 
patient  said  it  was  quite  disagreeable.  In  other  cases  no  reply  could  be 
obtained.  Final  notes  have  been  received  in  regard  to  28  patients. 
Five  are  still  alive  two  years,  ten  months,  six  months,  five  months,  and 
five  months  since  admission,  and  in  these  cases  the  disease  has  been 
present  five  years,  two  years,  two  years,  six  years,  and  four  years. 

Twenty-three  patients  are  dead,  the  length  of  time  they  lived  after 
being  seen  by  us  being  a  month  or  less  6  cases,  under  six  months  3  cases, 
under  a  year  6  cases,  over  a  year  6  cases,  two  years  1  case,  five  years 

I  case. 

As  seen  in  this  tabulation  of  23  cases  only  3  patients  have  lived  two 
years  or  more  since  their  first  visit,  so  that  it  would  seem  that  the  dura- 
tion of  life  after  perineal  prostatectomy  was,  as  a  rule,  longer  than  with 
a  catheter  life. 

X.  Cases  in  which  Neither  Operation  nor  Catheter  Life  was  Advised. — 
There  were  29  which  came  in  this  category.  These  cases  present  an 
unusual  and  interesting  group  because  of  the  lack  of  the  usual  severe 
obstruction  to  urination.  In  19  cases  a  catheter  had  never  been  used, 
in  4  cases  it  had  been  only  occasionally  employed.  In  1  case  acute 
retention  of  urine  was  present  on  admission  and  in  4  cases  the  catheter- 
was  employed  daily.  In  8  cases  the  difficulty  of  urination  was  con- 
siderable, in  2  cases  slight;  the  increased  frequency  was  considerable  in 

I 1  cases,  moderate  in  4,  and  slight  in  7  cases.    Pain  was  the  most  promi- 
nent symptom  in  most  cases  and  involved  various  regions  from  the 
chest  to  the  feet.     The  duration  of  symptoms  of  the  disease  was  less 
than  one  year  in  7  cases,  two  to  three  years  in  14  cases,  and  over  three 
years  in  7  cases. 

The  prostate  and  seminal  vesicles  were  considerably  enlarged  in  50  per 
cent,  of  the  cases,  so  the  lack  of  urinary  obstruction  was  not  due  to  the 
absence  of  prostatic  enlargement.  Among  the  21  patients  from  whom 
replies  have  been  obtained  in  only  5  did  catheterization  become  neces- 
sary, and  in  3  of  these  subsequent  operations  were  necessary  (two  supra- 
pubic  drainage  and  one  perineal  prostatectomy  with  relief  from  catheter 
life).  Among  the  21  patients  that  have  been  heard  from,  7  are  still 
alive,  3  of  them  six  months,  3  between  six  and  eleven  months,  and  1  one 
year  after  being  seen  by  us.  In  these  7  cases  the  patients  have  lived 
five,  four,  three,  and  two  years,  nine,  nine,  and  seven  months  since  the 
beginning  of  symptoms.  Fourteen  patients  have  died  since  our  exami- 
nation, having  lived  less  than  six  months,  4  cases;  between  six  and 
eleven  months,  2  cases;  one  year,  1  case;  two  years,  5  cases;  and  three 


THE  USE  OF  RADIUM  IN  CANCER  OF  THE  PROSTATE     715 

years,  2  cases.  The  total  length  of  time  these  patients  lived  after  be- 
ginning of  symptoms  was  under  six  months  1,  under  one  year  1,  over 
one  year  1,  two  years  4,  three  years  3,  four  years  1,  five  years  1,  eight 
years  1,  ten  years  1. 

This  class  of  cases  therefore  is  remarkable  for  the  extent  of  the 
involvement  and  the  freedom  from  marked  urinary  obstruction  for  long 
periods.  They  represent  a  class  in  which  early  diagnosis  is  difficult 
unless  rectal  examination  be  made  before  the  beginning  of  obstruc- 
tive symptoms  and  for  merely  slight  pain  and  discomfort  in  various 
regions  from  the  chest  down  (which  are  shown  to  be  reflexly  involved 
by  carcinoma  of  the  prostate).  The  presence  of  an  indurated  prostate 
in  any  such  case  should  lead  to  careful  investigation  and  probably 
exploratory  operation.  These  cases  show  the  great  importance  of 
rectal  examinations  as  a  routine  in  physical  examinations. 

THE  USE  OF  RADIUM  IN  CANCER  OF  THE  PROSTATE. 

Pasteau  and  Degrais  have  contributed  several  important  articles  on 
the  use  of  radium  in  cancer  of  the  prostate.  They  made  use  of  from 
20  to  50  mgs.  of  radium,  screened  by  a  thin  capsule  of  silver  and  by  the 
gum  coude  catheter,  in  which  it  was  placed  by  means  of  a  stylet.  A 
No.  17  catheter  was  used,  being  large  enough  to  let  the  escape  of  urine 
around  the  capsule  containing  radium,  thus  allowing  the  use  of  radium 
in  the  prostatic  urethra  for  several  hours. 

Their  first  patient  with  inoperable  cancer  of  the  prostate  and  adjacent 
portion  of  the  bladder  (hard,  nodular,  fixed  prostate,  irregular  cancer  of 
middle  lobe)  had  29  seances  of  radium  treatment  (20  to  50  mgs.  at  a 
time  and  usually  for  two  hours  at  a  time) .  He  had  three  treatments  in 
October,  1909,  13  in  the  next  eight  months,  7  in  the  year  1911,  and  4  in 
1912.  As  early  as  February,  1910,  the  tumor  had  apparently  disap- 
peared, and  numerous  examinations  since  (the  last  being  July,  1913) 
failed  to  show  a  return — the  prostate  being  soft,  small,  mobile,  and  the 
bladder  negative.  On  last  report  the  cure  had  been  maintained  almost 
four  years.  Another  case  was  that  of  a  man  seen  in  1909  with  a  hard, 
nodular,  fixed  prostate,  the  cancer  extending  into  the  region  of  one 
seminal  vesicle.  Series  of  radium  applications  were  made  in  July  and 
August,  1909,  with  a  tube  of  50  mgs.  remaining  in  place  for  two  hours, 
the  applications  being  repeated  in  September  and  October.  In  Febru- 
ary, 1910,  marked  improvement  was  found,  and  under  the  influence  of 
renewed  application  of  the  rays  by  the  end  of  1910  one-half  of  the  pros- 
tate was  much  softer.  Series  of  treatments — three  or  four  two-hour 
exposures  during  the  course  of  a  month  constituted  a  series — were  con- 
tinued for  two  years,  and  at  the  time  of  reporting  "  three  years  after  the 
commencement  of  the  treatment  the  extension  has  been  arrested  and 
the  patient  has  improved  greatly  in  health." 

In  another  case  eight  seances  of  three  hours  each  with  40  mgs.  of 
radium  caused  marked  shrinkage  and  softening  of  the  prostate.  Pas- 
teau remarks  that  they  have  observed  3  patients  in  all  of  whom,  when 


716  CANCER  OF  THE  PROSTATE 

they  came  under  observation,  the  prostate  was  enlarged,  nodular,  and 
very  hard,  in  whom  now  the  prostate  is  soft,  not  adherent,  and  does  not 
at  all  resemble  cancer.  Each  of  these  had  only  one  series  of  radium 
applications,  yet  they  are  reported  as  remarkably  benefited  if  not  cured. 
I  have  tried  the  urethral  catheter  method  of  Pasteau  with  some 
success,  but  have  found  it  inaccurate  and  unsatisfactory.  I  accordingly 
devised  (in  1914)  radium-carrying  instruments  of  metal,  which  are 
capable  of  being  used  with  a  cystoscope,  which  permits  of  accurate 
application  of  the  radium  in  the  bladder  and  at  the  vesical  orifice.  I 
have  also  introduced  the  use  of  the  rectal  route  for  applications  upon 
the  prostate  and  seminal  vesicles.  After  a  long  series  of  experiments 
and  treatments  I  have  shown  that  a  great  many  treatments  can  be 
made  through  the  rectum,  urethra,  or  bladder  if  a  new  place  is  selected 
each  time — the  sites  of  the  treatments  do  not  overlap.  The  results 
have  been  a  remarkable  series  of  cases  in  many  of  which  the  cancerous 
infiltration  of  prostate  and  vesicles  have  apparently  disappeared — 
a  marvelous  change — I  do  not  dare  to  call  them  cures. 


v 


FIG.  363. — Simplest  rectal  carrier. 

Perhaps  these  new  methods  may  be  best  illustrated  by  a  case — a  very 
advanced  one,  with  cancer  of  prostate  and  both  seminal  vesicles,  as 
shown  in  chart.  With  my  simplest  rectal  radium-carrier  (Fig.  363) 
applications  were  made,  with  the  guidance  of  a  gloved  finger  in  rectum, 
to  various  sites  along  the  carcinomatous  mass  in  vesicles  and  prostate, 
as  shown  by  the  chart  (Fig.  364).  The  exact  position  desired  is  main- 
tained by  a  mechanical  arm  and  clamp  attached  to  the  table  (Fig.  365). 
The  dates  of  each  treatment  and  "milligram  hours"  are  given  on  the 
chart.  The  patient  also  received  urethral  and  intra vesical  treatments 
shown  in  the  second  chart,  instruments  shown  in  Fig.  365  being  used. 
In  the  case  of  the  latter  instrument  a  cystoscope  is  used  and  one  can 
thus  direct  the  exact  application  in  the  bladder  so  as  to  radiate  a  semi- 
nal vesicle,  infiltrated  trigone,  or  an  intravesical  outgrowth  of  the 
carcinoma,  as  shown  in  Fig.  366.  The  method  employed  in  certain 
vesical  tumors  is  the  same.  The  results  obtained  in  this  case  have  been 
a  complete  disappearance  of  all  induration  and  enlargement,  both  in 
prostate  and  seminal  vesicles;  2125  mg.  hours  per  rectum  and  3125 
mg.  hours,  per  urethram  et  vesicam,  were  used.  Irritation  but  no 
burn  resulted,  and  normal  urination  was  largely  restored. 

I  have  now  used  radium  in  over  thirty  cases  of  prostatic  cancer  in 
the  past  two  years,  and  while  it  is  much  too  early  to  speak  of  permanent 
results,  there  is  no  question  that  really  wonderful  changes,  often  a  com- 


THE  USE  OF  RADIUM  IN  CANCER  OF  THE  PROSTATE     717 

plete  disappearance  of  the  tumor  mass,  have  been  brought  about  in  the 
majority  of  cases.  In  some  cases  obstruction  to  urination  has  per- 
sisted, and  in  four  cases  conservative  perineal  prostatectomy  has  been 


//. 


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FIG.  364. — Rectal  chart  showing  application  of  radium  to  prostate  and  seminal  vesicles. 

carried  out  with  success.  In  these  operations  a  replacement  of  the 
cancer  by  fibrous  tissue  has  been  found,  and  what  cells  remained  have 
often  shown  great  changes  in  nucleus,  vacuolization,  or  disappearance, 


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FIG.  365. — Mechanical  arm  and  clamp  attached  to  table  to  hold  radium  in  position. 

and  pronounced  colloid  degeneration  of  the  epithelium.  In  one  case  a 
"Punch"  operation  was  successful  in  removing  the  obstruction,  after 
prolonged  radiation  had  caused  a  disappearance  of  the  enlargement — 


718 


CANCER  OF  THE  PROSTATE 


leaving  only  a  fibrous,  contracted  prostatic  orifice.  I  have  used  the 
x-rays  and  radium  externally,  in  large  doses,  in  certain  cases,  particu- 
larly those  with  nerve  involvement. 


\. 


FIG.  366. — Urethral  and  bladder  chart. 


FIG.  367. — Author's  cystoscopic  radium  instrument,  No.  1. 


THE  USE  OF  RADIUM  IN  CANCER  OF  THE  PROSTATE     719 


The  method  of  puncture  with  emanation-carrying  needles,  as  carried 
out  recently  by  Janeway  and  Barringer,  is  very  greatly  limited,  and 
I  believe  less  generally  efficacious.  It  seems  probable,  therefore,  that 
we  are  on  the  verge  of  great  results  with  radium  in  the  treatment  of 


W-,W_  /7 


FIG.  368. — Sh  owing  use  of  radium  in  bladder  with  cystoscope  on  tumor  of  trigone 

cancer  of  the  prostate  and  vesicles.  The  accurate  methods  of  applica- 
tion and  of  charting,  above  detailed,  have  greatly  increased  the  value 
of  urethral  and  vesical  treatments,  and  also  opened  up  the  rectal  route 
as  a  most  effective  approach  to  the  prostate  and  vesicles. 


CHAPTER  XXI. 
SARCOMA  OF  THE  PROSTATE. 

BY  HUGH  HAMPTON  YOUNG,  M.D. 

THE  first  case  of  sarcoma  of  the  prostate  was  described  by  Stafford  in 
1839,  a  melanotic  tumor  in  a  child  five  years  of  age.  In  1858  Thompson 
found  6  cases  in  the  literature,  and  in  1902  Burckhardt  was  able  to 
collect  24  cases.  Proust  and  Vian,  in  1907,  published  34  "incontest- 
able" cases.  I  now  add  one  case  from  my  practice. 

Age. — In  the  35  cases  in  which  the  diagnosis  has  been  confirmed  by 
the  microscope,  15  were  under  ten  years  of  age;  12  were  between  ten 
and  forty-nine  years  of  age,  and  8  were  between  fifty  and  eighty  years 
of  age.  In  4  cases  the  patient  was  less  than  a  year  old  and  three 
patients  were  between  seventy  and  seventy-three  years  of  age. 

Various  types  of  sarcoma  have  been  present,  viz.,  small  cell,  6;  large 
cell,  3;  spindle  cell,  5;  polymorpho  cell,  4;  lymphosarcoma,  2;  angio- 
sarcoma,  2;  myxosarcoma,  3;  adenosarcoma,  1;  chondrosarcoma,  1; 
"rhabdomyoma,"3;  "fibroid,"  1. 

The  tumor  soon  reached  considerable  size  and  in  some  places  almost 
completely  filled  the  pelvis.  It  was  usually  oval  in  form,  regular  or 
slightly  lobulated,  but  occasionally  irregular  and  nodular.  The  con- 
sistence was  variable,  sometimes  firm,  sometimes  elastic,  sometimes  so 
soft  as  to  give  the  sensation  of  fluctuation.  In  many  cases,  however, 
the  induration  wras  considerable.  The  bladder  was  generally  pushed 
upward  and  forward  by  the  tumor,  which  grew  backward  beneath  the 
base  of  the  bladder.  The  mucous  membrane  was  generally  intact,  but 
occasionally  small  papillomatous  intravesical  outgrowths  were  present, 
almost  always  in  the  region  of  the  trigone.  The  rectum  was  usually 
compressed,  flattened,  but  its  walls  were  rarely  infiltrated  and  the 
mucous  membrane  was  healthy  in  all  cases.  The  urethra  was  almost 
always  invaded  and  generally  strictured.  Occasionally  intra-urethral 
polyps  were  present.  The  seminal  vesicles  have  generally  been  found 
involved.  The  perirectal  and  retroperitoneal  tissues  were  often 
invaded,  as  were  also  the  peritoneum,  the  intestines  and  the  pelvic 
bones.  The  lymph  glands  were  involved  in  7  of  the  35  cases,  but 
metastases  elsewhere  occurred  more  frequently. 

That  sarcoma  of  the  prostate  is  a  rare  disease  is  shown  by  the  fact 
that  only  1  case  has  been  detected  among  the  immense  number  of  cases 
seen  at  the  Hopital  Necker  in  Paris.  I  have  personally  had  1  case  in 
which  the  diagnosis  of  sarcoma  of  the  prostate  was  positively  made  by 
microscopic  examination,  but  in  our  service  there  have  been  2  cases  in 
which  a  clinical  diagnosis  of  sarcoma  has  been  made.  My  patient,  a 
(720) 


TREATMENT  721 

man,  aged  fifty-one  years,  had  suffered  with  pain  in  the  lower  abdomen 
and  rectum  for  fourteen  months.  Urinary  trouble  had  been  present  for 
six  months,  but  had  only  recently  become  marked.  On  rectal  examina- 
tion an  immense  smooth  mass,  which  almost  filled  the  pelvis,  was  felt. 
It  was  very  soft  and  homogeneous  to  the  touch  and  almost  completely 
obliterated  the  rectum.  Only  40  c.c.  residual  urine  was  present.  Per- 
ineal  prostatectomy  was  performed  and  the  tumor  found  to  spring  from 
the  upper  portion  of  the  prostate,  the  anterior  two-thirds  of  which  was 
apparently  normal.  The  urethra  and  bladder  were  not  invaded,  but 
the  latter  was  greatly  elevated  by  the  huge  retrovesical  mass.  The 
tumor  was  composed  of  soft  hemorrhagic  material  which  was  easily 
scooped  out  with  the  finger.  The  patient  recovered  and  was  able  to 
void  urine  without  difficulty  and  lived  for  almost  a  year.  The  micro- 
scope showed  a  sarcoma  of  mixed-cell  type. 

Symptoms. — Proust  has  divided  his  study  into  those  of  early  age, 
24  cases,  and  those  of  advanced  age,  10  cases.  Among  these  of  early 
age  the  first  symptom  was  usually  pain,  and  this  did  not  come  on  until 
obstruction  to  urination  developed.  Constipation  was  often  present. 
In  most  cases  the  tumor  had  reached  great  size  before  any  symptoms 
were  present.  Among  those  patients  older  than  thirty  years  of  age  the 
development  was  slower.  In  rare  cases  sudden  retention  of  urine 
occurred,  but  often  there  was  very  little  obstruction  to  either  urine  or 
feces.  At  times,  owing  to  its  softness,  it  is  difficult  to  differentiate  from 
abscess.  In  the  adult,  sarcoma  of  the  prostate  is  generally  more 
irregular  than  hypertrophy,  produces  less  lengthening  of  the  canal  and 
is  more  infiltrated.  Sarcoma  is  less  often  accompanied  by  hematuria 
than  carcinoma,  which  is  usually  much  harder  and  characterized  by 
indurated  prolongations  into  the  region  of  the  seminal  vesicles.  In  my 
case  the  consistence  was  much  softer  than  is  ever  seen  in  simple  hyper- 
trophy, and  the  immense,  smooth,  globular  mass  could  never  have  been 
mistaken  for  carcinoma. 

Treatment. — In  young  patients  operations  have  been  absolutely 
unsuccessful.  In  the  adult  the  results  have  not  been  brilliant,  but 
several  cases  in  which  the  patient  was  relieved  for  a  considerable  period 
are  on  record.  Spanton,  in  1882,  enucleated  through  the  perineum  a 
very  large  sarcoma  of  the  prostate,  but  the  patient  died  on  the  following 
day.  In  1894  Socin  removed  a  tumor  the  size  of  two  fists  through  the 
anus  and  rectum,  without  injury  of  the  urethra  or  bladder.  The 
rectum  was  then  sutured.  The  patient  showed  no  evidence  of  recur- 
rence for  three  years.  Verhoogen,  in  1898,  extirpated  the  prostate  with 
its  capsule  and  urethra  after  division  of  the  membranous  urethra.  The 
patient  died  later  of  a  recurrence  of  the  sarcoma.  McGowan  reported 
a  case  in  which  the  patient  was  apparently  cured,  but  died  four  years 
later  of  cancer  of  the  liver.  A  patient  of  Fuller's  lived  eleven  months. 

In  my  case  it  was  impossible  to  perform  radical  excision,  and  I  could 
only  scoop  the  broken-down  material  within  the  capsule.  The  ob- 
struction to  urination  was  removed,  but  the  patient  died  one  year 
later. 

H  u    i — 46 


722  SARCOMA  OF  THE  PROSTATE 

Owing  to  the  fact  that  sarcoma  of  the  prostate  generally  begins  in  the 
upper  portion  of  the  posterior  part  of  the  gland  and  rapidly  involves  the 
capsule  and  retrovesical  structures,  it  seems  probable  that  radical 
measures  can  never  be  as  successful  as  in  cancer.  Sarcoma  may  remain 
encapsulated,  as  in  Socin's  case,  and  a  complete  extirpation  through  the 
perineum  may  be  possible.  The  suprapubic  route  will  probably  not  be 
available,  owing  to  the  retrovesical  character  of  the  growth.  Supra- 
pubic  drainage  may  be  necessary  in  some  cases. 


CHAPTER  XXII. 
CALCULUS  DISEASE  OF  THE  PROSTATE. 

BY  HUGH  HAMPTON  YOUNG,  M.D. 

PROSTATIC  calculi  may  be  divided  into  two  groups,  on  account  of  their 
origin  and  location:  (1)  Calculi  which  lodge  in  the  prostatic  urethra, 
having  escaped  from  the  kidney,  bladder,  or  seminal  vesicles,  and  the 
small  group  of  cases  in  which  the  stone  is  primarily  formed  in  the  pos- 
terior urethra.  (2)  Calculi  which  are  formed  in  the  substance  of  the 
prostate  gland,  the  true  prostatic  calculi.  This  second  group  is  entirely 
distinct  in  origin  and  nature  from  the  urinary  calculi. 

On  account  of  the  intimate  relation  existing  between  corpora  amy- 
lacea  and  prostatic  calculi,  it  is  necessary  to  consider  the  forme  r  before 
taking  up  the  subject  of  true  prostatic  stones. 

Etiology. — This  is  uncertain,  as  is  the  case  with  calculi  elsewhere. 
Various  authors  have  ascribed  to  corpora  amylacea  a  causative  influ- 
ence. According  to  Thompson,  corpora  amylacea,  having  attained  the 
size  of  their  inclosing  follicle,  act  as  foreign  bodies,  and  in  consequence 
of  the  general  law  that  all  mucous  membranes  when  sufficiently  irri- 
tated throw  out  a  deposit  of  calcium  phosphate  and  carbonate,  ulti- 
mately form  calculi.  The  amount  of  earthy  matter  varies  from  45 
per  cent,  in  the  concretion  to  85  per  cent,  in  the  calculus.  The  number 
of  calculi  present  may  vary  from  one  to  several  hundred.  They  are 
generally  a  little  less  than  that  of  a  barley-seed  in  diameter,  but  they 
may  range  in  size  from  2  mm.  to  3  or  4  cm. 

Symptoms. — Stones  deeply  embedded  in  the  gland  cause,  as  a  rule 
but  slight  disturbance,  and  the  gland  may  be  filled  with  stones  and  yet 
no  marked  symptoms  occur.  Irritability  of  the  bladder  and  pain  are 
sometimes  present.  Frequency  or  hesitancy  of  urination  is  seen  oftener 
than  initial  or  terminal  hematuria,  the  latter  being  much  more  constant 
and  characteristic  in  the  case  of  vesical  stone.  Retention  or  incon- 
tinence occurs  especially  if  stones  are  located  in  the  middle  lobe.  Occa- 
sionally the  genital  symptoms  are  marked;  testicular  pain,  frequent 
ejaculations,  feeble  erections  and  a  condition  of  semipriapism  having 
been  noted  in  different  cases.  Rectal  palpation  in  the  early  stages  may 
disclose  an  enlarged  but  not  indurated  gland.  When  the  calculi  are  not 
near  the  posterior  surface,  the  gland  is  smooth  and  regular;  as  the 
stones  approach  the  periphery  it  becomes  irregular  and  the  hardness 
may  be  very  marked.  When  two  or  more  stones  are  in  contact, 
crepitus  may  be  elicited.  It  may  be  absent,  however,  even  when  a 
great  many  stones  are  present.  When  the  stone  is  in  communication 
with  the  urethra,  a  sound  will  give  crepitus,  and  considerable  additional 

(723) 


724  CALCULUS  DISEASE  OF  THE  PROSTATE 

advantage  is  obtained  by  the  simultaneous  rectal  palpation  with  the 
finger.  If  a  rectal  or  perineal  fistula  exists,  the  passage  of  a  probe 
through  it  frequently  leads  to  the  stone.  With  the  cystoscope  or  the 
urethroscope  the  calculus  can  sometimes  be  seen  and  the  .r-ray  has  been 
used  with  considerable  advantage. 

The  complications  occasioned  by  prostatic  stone  are,  briefly :  abscess, 
fistula,  prostatic  hypertrophy,  incontinence  or  retention  of  urine,  sexual 
disorders,  including  deferentitis  and  epididymitis. 

Treatment. — When  the  stone  communicates  with  the  prostatic  ure- 
thra, it  may  be  removed  through  the  bladder  by  suprapubic  cystotomy. 
In  cases  where  the  stone  is  more  or  less  completely  embedded  in  the 
prostatic  substance  the  suprapubic  route  is  contra -indicated.  The 
perineal  route  is  preferable  in  most  cases.  The  prostate  should  be 
exposed  as  for  a  perineal  prostatectomy,  and  opened  either  upon  a 
grooved  staff  or  upon  a  prostatic  tractor  which  has  previously  been  in- 
serted. In  young  patients  the  calculi  are  usually  not  great  in  number 
and  it  is  not  necessary  to  remove  gland  tissue.  The  multiple  seed  cal- 
culi which  are  found  scattered  throughout  the  gland  are  almost  always 
associated  with  prostatic  hypertrophy  or  obstructive  prostatitis,  and 
prostatectomy  is  indicated,  being  the  simplest  way  of  removing  the 
calculi. 


INDEX. 


A 


ABNORMALITIES  of  scrotum,  449 
Abscess,   peri-urethral,   anterior  gonor- 
rheal urethritis  and,  304 
stricture  of  female  urethra  and, 

364 
prostatic,  acute  posterior  gonorrheal 

urethritis  and,  306 
gonorrheal  stricture  of  urethra 

and,  392 
of  scrotum,  452 

suburethral,  acute  gonorrheal  ure- 
thritis in  female  and,  379 
Absence  of  penis,  201 

of  urethra  in  female,  349 
Actinomycosis  of  penis,  236 
Adenitis,   inguinal,   283.     See   Inguinal 

Adenitis. 

Adenocarcinoma  of  scrotum,  460 
Adherent  penis,  202 
Alexander,  Samuel,  historical  sketch  of, 

31 
Amplification  of  field  in  direct  optical 

system,  58 
Andrew's  "bottle"  operation  for  hydro- 

cele,  471 
Anesthesia  in  cystoscopy,  70 

in  gonorrheal  stricture  of  urethra, 

394,  398 
Anorchism,  430 
Antigonococcus  serum  in  treatment  of 

gonorrheal  urethritis,  327 
Aspiration  in  treatment  of  hydrocele,  470 
Atrophic  phimosis,  224 
Atrophy  of  testicle,  430 
Autoserotherapy  in  treatment  of  hydro- 
cele, 468 


B 


BALANITIS,  230 

erosive  and  gangrenous,  264 
bacteriology  of,  264 
chills  in,  269 
definition  of,  264 
diagnosis  of,  269 
edema  in,  269 
etiology  of,  264,  266 
fever  in,  269 
pathology  of,  266 
symptoms  of,  268 
treatment  of,  270 


Balanoposthitis,   acute  anterior  gonor- 
rheal urethritis  and,  305 
in  inflammation  of  penis,  231 
phimosis  and,  224 
Beck's  operation  for  epispadias,  213 

for      glandular      hypospadias. 

204 

for  scrotal  hypospadias,  208 
Bigelow,  Henry  J.,  historical  sketch  of, 

24 
Bigelow's  evacuating  apparatus,  40,  41 

lithotrite,  40,  41 
Bladder,  calculus  of,  diagnosis  of,  from 

obstruction  of  prostate,  590 
cancer  of  prostate  and,  680 
diseases  of,  symptoms  of,  142 
diverticula  of,  pyelography  and,  160 
examination  of,  instrumental,  119 

cystoscopy  in,  119 
in  genital  tuberculosis,  521 
gonococcal  infection  of,  334 
obstruction  of,  causes  of,  139 

diagnosis  of,  140 
resection  of,  transperitoneal  partial, 

historical  sketch  of,  43 
speculum,  Watson's,  56 
stone  in,  pyelography  and,  160 
surgery  of,  historical  sketch  of,  39 
syphilis  of,  169 

pathology  of,  181 
secondary,  173 
age  in,  181 
cystoscopy  in,  181 
tertiary,  175 
age  in,  182 
cystoscopy  in,  182 
diagnosis  of,  182 
hematuria  in,  182 
pain  in,  182 
pollakiuria  in,  182 
spinal-cord  affections  simu- 
lating, 184 
symptoms  of,  182 
treatment  of,  183 

tumors  of,  diagnosis  of,  from  obstruc- 
tion of  prostate,  589 
operations  for,  historical  sketch 

of,  43 
Bevan's     operation     for     undescended 

testicle,  438-441 

Bottini  electrocautery  operation  in  can- 
cer of  prostate,  712 
Bougie  catheter,  582 

(725) 


726 


INDEX 


Bougie  in  gonorrheal  stricture  of  ure- 
thra, 395,  398 

Brown's  catheterizing  cystoscope,  63 
Bryson,  John  P.,  historical  sketch  of,  30 
Bubo,    inguinal,    283.        See    Inguinal 

Adenitis. 

Buerger's  catheterizing  cystoscope,  66 
combination  operating  cystoscope, 

86    • 

cysto-urethroscope,  96,  97,  348 
operating  cystoscope,  85 

cysto-urethroscope,  105 
prismatic  cystoscope,  65 
Burns  of  penis,  229 


CABOT,  ARTHUR  T.,  historical  sketch  of, 

29 
Cabot's  operation  of  resection  of  urethra 

in  gonorrheal  stricture,  411 
tampon,  55 

Calculi,  prostatic,  pyelography  and,  159 
removal    of,    operative   cystoscopy 

and,  90 

of  scrotum,  454 

ureteral,  descent  of,  operative  cystos- 
copy and,  90 

diagnosis  of,  operative  cystos- 
copy and,  88 
pyelography  and,  159 
Calculus  of  bladder,  diagnosis  of,  from 

obstruction  of  prostate,  590 
disease  of  prostate,  723 
of  urethra  in  female,  356 
vesical,    operations    for,    historical 

sketch  of,  39 
Cancer  of  prostate,  657.    See  Prostate, 

cancer  of. 
Carcinoma   of  penis,   237.    See   Penis, 

carcinoma  of 
of    prostate,    657.     See    Prostate, 

cancer  of. 
of  scrotum,  460 
stricture  of  urethra  and,  416 
of  urethra  in  female,  362 
Cardiovascular   examination,    diagnosis 

of  lesions  of  urinary  tract  and,  136 
Cartilaginous  and  bony  formations  of 

penis,  234 

Caruncle  of  urethra  in  female,  358 
Castration  in  cancer  of  prostate,  713 
Catarrhal  prostatitis,  pathology  of,  300 
Catheter-trauma  of  urethra  in  female, 

353 
Catheterization  in  cancer  of  prostate, 

713 
ureteral,  79,  122 

cystoscope  in,  direct,  83 
Elsner-Braasch,  84 
indirect,  79 
operative,  89 
endoscope  in,  Kelly's,  84 
Kelly-Pawlik,  85 
Luy's,  85 


Catheterization,  ureteral,  lack  of  drain- 
age after,  123 
obstruction  in,  122 
wax-tip  bougies  in,  122 
of  urethra  in  female,  353 
Catheterizing  cystoscopes,  65 
Brown's,  63 
Buerger's,  66 
composite,  68 
direct,  66 

Elsner-Braasch,  68 
indirect,  66 
Nitze-Albarran,  66 
universal,  68 
Catheters,  bougie,  582 
de  Pezzer,  615 

Pilcher  modification  of,  615 
Mercier  bicoude,  582 

coude,  582 
soft-rubber,  582 
Cautery   in  treatment   of   caruncle   of 

urethra  in  female,  359 
Cavernositis,  acute,  233 

anterior    gonorrheal   urethritis 

and,  305 
etiology  of,  233 
symptoms  of,  233 
chronic,  233 

etiology  of,  234 
diffuse,  233 

priapism  in,  233 
pyemia  in,  233 
Cellulitis  of  scrotum,  452 
Chafing  of  scrotum,  450 
Chancre,  241 

chancrous  erosions,  245 

ulceration,  245 
classification  of,  244 
definition  of,  241 
diagnosis  of,  247 

dark-ground    illumination    in, 

247 

Nernst  lamp  in,  248 
Reichert     instrument 

in,  248 
differential,  255 

from  scabies,  255 
materials  for,  obtaining  of,  249 

preparation  of,  249 
Noguchi  butyric  acid  test  in, 

255 
Ross-Jones      modification      of 

Nonne  test  in,  255 
spinal  fluid  examination  in,  254 
staining  methods  in,  250 

Giemsa's,  250,  251 
Levaditi's,  251,  252 
Wassermann  reaction  in,  253 
endo-urethral,  162 
discharge  in,  162 
induration  in,  162 
pain  in,  162 
symptoms  of,  162 
etiology  of,  241 
hard,  241 
histology  of,  243 


INDEX 


727 


Chancre,  Hunterian,  241 

incubation  in,  244 

indurated  papule,  245 

Hunterian,  245 
parchment,  245 

of  meatus,  161 

symptoms  of,  162 

pain  in,  245 

pathology  of,  243 

prognosis  of,  256 

prophylaxis  in,  256 

soft,  278 

Spirochseta  pallida  in,  241 

synonyms  of,  241 

treatment  of,  256 
excision  in,  256 
general,  256 
local,  256 
salvarsan  in,  256 
Chancroid,  278 

complications  of,  282 

definition  of,  278 

diagnosis  of,  281 

Ducrey-Unna  bacillus  and,  279 

etiology  of,  278 

location  of,  281 

lymphadenitis  and,  283 

lymphangitis  and,  283 

mixed  sore  in,  281 

pain  in,  281 

paraphimosis  and,  283 

pathology  of,  279 

phagedena  and,  283 

phimosis  and,  282 

sequelae  of,  283 

stricture  of  urethra  and,  416 

symptoms  of,  279 

synonyms  of,  278 

treatment  of,  282 
Chimney-sweep's  cancer,  459 
Chondroma  of  penis,  237 
Chordee,  303 
Chylocele,  477 

diagnosis  of,  from  hydrocele,  467 

treatment  of,  477 

Circumcision  and  tuberculosis  of  penis, 
235 

Cleft  penis,  202 

Cloudy  urine  in  diagnosis  of  lesions  of 

genito-urinary  tract,  132 
Complement-fixation  test,  296 
cases  used  in,  297 
in  chronic  anterior  gonorrheal 

urethritis,  309 
gonorrheal  prostatitis,  311 
diagnosis  of  lesions  of  urinary 

tract  and,  135 
effect  of  vaccines  in,  297 
practical  value  of,  298 
time  of  appearance,  297 

of  disappearance,  297 
weakly  positive,  297 
Composite      catheterizing      cystoscope, 

68 
Concealed  penis,  201 

treatment  of,  201 


Concretions  in  appendix,  roentgenology 

of  urinary  tract  and,  150 
Condyloma  of  penis,  237 
Congenital  hydrocele,  475 

malformations  of  penis,  198 
phimosis,  223 

stricture  of  urethra  in  male,  414 
Corpora  cavernosa,  anatomy  of,  193 
Corpus  Highmori,  422 

spongiosum,  anatomy  of,  195 
Coverings  of  penis,  anatomy  of,  196 
Cowperitis,   acute  posterior  gonorrheal 

urethritis  and,  306 
pathology  of,  300 
Cowper's  glands,  anatomy  of,  289 
Cutaneous  diseases  of  scrotum,  450 
Cylindroid  syphiloma  of  urethra,  165 
Cystectomy,  total,  historical  sketch  of, 

44 
Cystic  bodies,  operations  on,  operative 

cystpscopy  and,  91 
Cystitis,  acute  gonorrheal  urethritis  in 

females  and,  378 
Cystoscopes,  58,  62 
accessories  for,  69 

lighting  apparatus,  "69 
sterilization  of,  69 
catheterizing,  65 
Buerger's,  66 
composite,  68 
direct,  66 

Elsner-Braasch,  68 
indirect,  66 
Nitze-Albarran,  66 
universal,  68 
direct,  58,  62 

Brown's  catheterizing,  63 
Lewis's  universal,  63 
indirect,  65 
Kelly's,  349 
Nitze,  60,  62 
operating,  Buerger's,  85 

combination,  86 
prismatic,  65 

Buerger's,  65 
Otis-Brown-Nitze,  65 
selection  of,  105 

in  ureteral  catheterization,  direct,  83 
Elsner-Braasch,  84 
indirect,  79 
Cystpscopy,  anesthesia  in,  70 

in  examination  of  bladder,  119 

contra-indications  to,  120 
indications  for,  120 
introduction  of  instrument  in,  72 
lubricants  in,  71 
observation,   elementary  principles 

of,  76 
induced  movement  of  field  in, 

77 

light  in,  79 
magnification  in,  77 
problem  of  sphincter  in,  78 
relation  of  field  and,  76 
routine  in,  73 
technic  of,  72 


728 


INDEX 


Cystoscopy  in  obstruction  of  prostate. 

584 

dangers  of,  587 
technic  of,  584 
value  of,  586 
operative,  85 

catheterization  and,  89 
diagnosis  of  ureteral  calculi  by 
means  of  wax-tipped  cathe- 
ters and,  88 

dilating  ureters  and  facilitat- 
ing descent  of  ureteral  calculi 
and,  90 

excision  of  ulcers  and,  91 
exploratory  excision  and,  91 
high-frequency    treatment    of 

tumors  and,  89 
intravesical  biopsy  and,  91 
methods  in,  88 
operations  on  cystic  bodies  and, 

91 

on  ureterocele  and,  91 
removal  of  calculi  and,  90 
of  foreign  bodies  and,  90 
of     phosphatic     encrusta- 
tions and,  90 

snaring  of  papillomata  and,  91 
technic  of,  88 

with     recessive     type     of 

instrument,  88 
with  scissors  type  of  instru- 
ment, 88 

ureteral  meatotomy  and,  91 
preparations  for,  71 
solution  for,  70 

suprapubic,  in  enlargement  of  pros- 
tate, 611 

in  syphilis  of  bladder,  181,  182 
syringes  in,  71 
table  for,  70 
ureteral  catheters  in,  70 
Cysto-urethroscopes,  95 
Buerger's,  96,  348 
Goldschmidt's,  96 
McCarthy's  close  vision,  348 
operating,  104 

technic  and  application  of,  104 
selection  of,  105 

Cysto-urethroscopy,  technic  of,  96 
Cysts  of  penis,  dermoid,  237 

epithelial,  236 
of  scrotum,  sebaceous,  452 
of  urethra  in  female,  360 


DARK-GROUND  illumination  in  diagnosis 

of  chancre,  247 

Dartos  of  penis,  anatomy  of,  196 
of  scrotum,  anatomy  of,  447 
de  Pezzer  catheter,  615 

Pilcher  modification  of,  615 
prpstatic  tractor,  642 
Dermoid  cysts  of  penis,  237 
Diathetic  urethritis,  334 


Dilatation    in    gonorrheal    stricture    of 

urethra,  398 
bulbous,  399 
dilators  in,  399 
filiforms  and  followers 

in,  398 
instruments    required 

for,  398 
at  meatus,  399 
membranous,  399 
pendulous,  399 
scrotal,  399 
sounds  in,  399 
technic  of,  399 
woven  bougies  in,  399 
Direct  cystoscope,  58 

catheterizing,  66 
in  ureteral  catheterizaticn,  83- 
Dislocation  of  penis,  220 

of  testicle,  442 
Diverticula  of  bladder,  pyelography  and, 

160 

Diverticulum  of  urethra  in  female,  366 
Double  penis,  199 

urethra  in  female,  350 
Dropsy  in  acute  parenchymatous  syphil- 
itic nephritis,  188 
Ducrey-Unna   bacillus,    chancroid   and, 

279 

Ductuli  efferentes,  417 
Ductus  epididymidis,  417 
Duplay's  operation  for  epispadias,  214 
for  glandular  hypospadias,  204 
for    penoscrotal    hypospadias, 
207 


ECTOPIA  of  testicle,  432 

Eczema  marginatum  of  scrotum,  451 

of  scrotum,  450 
Eczematous  urethritis,  334 
Edema  of  penis,  230 
of  scrotum,  452 

of  skin  in  torsion  of  testicle,  445 
Elephantiasis  of  penis,  236 
of  scrotum,  filarial,  454 

non-filarial,  459 
Elsner-Braasch  catheterizing  cystoscope, 

68 

cystoscope  in  ureteral  catheteriza- 
tion, 84 

Emphysema  of  scrotum,  453 
Encysted  hydrocele  of  cord,  476 
Endoscope,  Kelly's,  68 
Luy's,  69 
in  ureteral  catheterization,  Kelly's, 

84 

Kelly-Pawlik,  85 
Luy's,  85 

Endoscopic  tubes,  68 
Endo-urethral  chancre,  162 
Enlargement  of  prostate,  575 
Epididymectomy,  fechnic  of,  528 
Epididymis,  anatomy  of,  422 


INDEX 


729 


Epididymis,  blood  supply  of,  425 
histology  of,  425 
lymphatics  of,  426 
nerves  of,  426 
physiology  of,  426 
tuberculosis  of,  498,  499 
diagnosis  of,  499 
pathology  of,  511 
prognosis  of,  499 
symptoms  of,  519 
treatment  of,  499 
Epididymitis,  gonorrheal,  330 
diagnosis  of,  331 
etiology  of,  330 
pathology  of,  330 
prognosis  of,  331 
sterility  in,  334 
stricture  of  urethra  and,  392 
symptoms  of,  330 
treatment  of,  331 
operative,  332 
vaccines  in,  332 

Epididymovasectomy,  technic  of,  528 
Epispadias,  213 
etiology  of,  214 
in  female,  351 

treatment  of,  351 
operations  for,  214 
Beck's,  216 
Duplay's,  214 
Thiersch's,  214 
treatment  of,  214 
Epithelial  cysts  of  penis,  236 
Erosive  balanitis,  264 
Erysipelas  of  penis,  232 

of  scrotum,  453 

Erythema  intertrigo  of  scrotum,  450 
Essential  hematuria,  184 
Esthiomene,  260 

causes  of  death  in,  261 
course  of,  261 
diagnosis  of,  261 
pathology  of,  262 
symptoms  of,  261 
treatment  of,  263 
Evacuating    apparatus,    Bigelow's,    40, 

41 
Eversion    in   treatment   of     hydrocele, 

471 
Extravaginal  spermatocele,  477 


F 


FASCIA  of  penis,  anatomy  of,  196 
Fibroma  of  penis,  237 
Filarial  elephantiasis  of  scrotum,  454 
Fistula  in  genital  tuberculosis,  520 
Follicular  prostatitis,  pathology  of,  300 
Foreign   bodies,   removal  of,   operative 

cystoscopy  and,  90 
stricture  of  urethra  and,  416 
Fourth  venereal  disease,  264 
Freezing  of  penis,  225 
Frenum  of  penis,  disease  of,  223 


G 


GALACTOCELE,  477 

Gall-stones,    roentgenology    of   urinary 

tract  and,  151 
Galvanocautery  in  treatment  of  caruncle 

of  female  urethra,  359 
Gangrene  of  penis,  234 

of  scrotum,  453 
Gangrenous  balanitis,  264 
Genital  tuberculosis,  498 
bladder  in,  521 
diagnosis  of,  523 
etiology  of,  517 
fever  in,  521 
fistula  in,  520 
incidence  of,  500 
pain  in,  520 
pathogenesis  of,  503 
pathology  of,  509 
prognosis  of,  524 
sex  function  in,  522 
symptoms  of,  519 
treatment  of,  527 
urine  in,  521 
ulcers,  £40 

classification  of,  241 
historical  review  of,  240 
non-venereal,  277 
venereal,  241 

chancroid,  278 

erosive     and     gangrenous 

balanitis,  264 
syphilis,  241 

chancre,  241 
esthiomene,  or  syphil- 
itic hypertrophy  of 
vulva   with  ulcera- 
tions,  260 

gumma  or  chancre  re- 
dux,  259 

ulcerative  papule,  259 
Genitals,  diseases  of,  symptoms  of,  144 
Genito-urinary  diseases,   symptoms  of, 

141 

genital,  144 
physical    examination     of 

women,  145 
prostatic,  142 
renal  pelvic,  143 
seminal  vesicular,  142 
ureteral,  142 

in  female,  144 
urethral,  141 
vesical,  142 
organs,  syphilis  of,  161 
tuberculosis,  incidence  of,  500 
Giemsa's  staining  methods  in  diagnosis 

of  chancre,  250,  251 
Giraldes,  organ  of,  417 
Glands,  Cowper's,  anatomy  of,  289 
of  Littre,  anatomy  of,  289 
prostate,  anatomy  of,  289 
urethral,  abscess  of,  anterior  gonor- 
rheal urethritis  and,  304 
anatomy  of,  289 


730 


INDEX 


Glandular  hypospadias,  operations  for, 

204 

Goldschmidt's  cysto-urethroscope,  96 
Gonococcal  infection  of  bladder,  334 

of  kidney,  334 
Gonococcus,  292 

appearance  of,  atypical,  293 

typical,  293 

collection  of  material  for  examina- 
tion, 295 

complement-fixation  test  and,  296 
cases  used  in,  297 
effect  of  vaccines  on,  297 
practical  value  of,  298 
time  of  appearance,  297 
of  disappearance, 

297 

weakly  positive,  297 
cultural  methods,  295 
fixing  of,  293 
isolation  of,  294 

microscopic  characteristics  of,  292 
preparation  of  slide,  292 
source  of  specimen  of,  292 
spreading  on  slide,  292 
staining  of,  293 

Gram  stain  in,  294 
methylene  blue,  293 
Gonorrhea,  286 

acute   anterior.       See   Gonorrheal 

urethritis,  acute  anterior, 
diagnosis  of,    methylene    blue 

stain  in,  293 

posterior.     See  Gonorrheal  ure- 
thritis, acute  posterior, 
chronic,  diagnosis  of,  methylene  blue 

stain  in,  294 
prevalence  of,  286 
reasons  for,  286 
remedy  for,  287 
treatment  of,  313.    See  Gonorrheal 

urethritis,  treatment  of. 
Gonorrheal  epididymitis,  330 
diagnosis  of,  331 
etiology  of,  330 
pathology  of,  330 
prognosis  of,  331 
sterility  in,  333 
symptoms  of,  330 
treatment  of,  331 
operative,  332 
vaccines  in,  332 

prostatitis,  acute,  pathology  of,  300 
chronic,      complement-fixation 

test  in,  311 
course  of,  311 
diagnosis  of,  311 

from  inflammation  of 

verumontanum,  312 

from     non-gonorrheal 

prostatitis,  312 
from  seminal  vesiculi- 

tis,  312 

stricture  of  urethra,  386 
course  of,  393 
cure  of,  393 


Gonorrheal  stricture  of   urethra,   diag- 
nosis of,  394 
epididymitis  and,  392 
etiology  of,  386 
form  of,  388 
location  of,  387 
pathology  of,  386 
treatment  of,  397 

anesthesia  in,  398 
antisepsis  in,  398 
bougies  in,  398 
dilatation  in,  398 
meatotomy  in,  403 
operative,  402 
palliative,  397 
preventive,  397 
resection  of  fistula,  412 

of  urethra,.  411 
sounds  in,  399 
urethrotomy  in,  exter- 
nal, 405,  409 
internal,  404 

urethritis,  acute  anterior,  abscess  of 
urethral  glands  and, 
309 
balanoposthitis     and, 

305 
burning  on  urination 

in,  303 

cavernositis  and,  305 
course  of,  304 
diagnosis  of,  304 
discharge  in,  303 
incubation  in,  302 
inguinal  adenitis  and, 

305 

invasion  in,  302 
lymphangitis  and,  305 
painful    erections    in, 

303 
peri-urethral     abscess 

and, 304 

peri-urethritis  and,304 
red  and  swollen  mea- 

tus  in,  303 
spongeitis  and,  305 
symptoms  of,  302 
urine  changes  in,  303 
variations  in  attack  of, 

303 

etiology  of,  298 
pathology  of,  299 
posterior,    acute     seminal 
vesiculitis  and,  307 
complications  of,  306 
course  of,  306 
cowperitis  and,  306 
frequency    of    urina- 
tion in,  305 
prostatic  abscess  and, 

306 

symptoms  of,  305 
urinary      change     in, 

306 

case  treatment  of,  319 
chronic  anterior,  cause  of,  307 


INDEX 


731 


Gonorrheal  urethritis,  chronic  anterior, 
complement-fixation 
test  in,  309 
complications  of,  309 
diagnosis  of,  309 
instrumentation,  308 
pain  in,  308 
palpation  in,  308 
symptoms  of,  307 
urethral  discharge  in, 

308 

urethroscopy  in,  308 
urine  in,  308 
pathology  of,  301 
posterior,  complications  of, 

312 

disturbances  in  sexual 
f  unctions  in,3 10 
of  urination  in,3 10 
etiology  of,  309 
exacerbations  in,  310 
instrumentation  in,311 
pain  in,  310 
palpation  in,  310 
pus  in  urine  in,  310 
symptoms  of,  309 
urethral  discharge  in, 

310 

urethroscopy  in,  311 
in  female,  370 
acute,  373 

complications  of,  378 
cystitis  and,  378 
etiology  of,  373 
examination  in,  374 
suburethral      abscess 

and,  379 

symptoms  of,  373 
treatment  of,  376 
urethroscopy  in,  375 
chronic,  379 

diagnosis  of,  381 
pathology  of,  380 
symptoms  of,  380 
treatment  of,  382 
urethroscopy  in,  381 
urine  in,  381 
examination  for,  371 
pyuria    without    urethral 

discharge  in,  371 
prophylaxis  against,  313 
treatment  of,  313 
anodynes  in,  3 15 
anterior  urethral  injections 

in,  315 
antigonococcus   serum    in, 

327 

balsamics  in,  314 
bowels  in,  314 
bulbous  bougie  in,  317 
dilatation  in,  317 
discharge  in,  314 
food  in,  314 
hygienic      cleanliness     in, 

314 
internal  medication  in,  314 


Gonorrheal  urethritis,  treatment  of, 
posterior  urethral  irriga- 
tion in,  316 

prostatic  massage  in,  316 
rest  in,  314 

urethral  instillations  in,318 
vaccines  in,  327 
Gouley's  tunnelled  sound,  54 
Gross,  Samuel  D.,  historical  sketch  of,  21 
Guinea-pig    inoculation,    diagnosis     of 

lesions  of  urinary  tract  and,  134 
Gumma  of  kidney,  190 

Wassermann  reaction  in,  191 
of  penis,  235,  259 
Gunshot  wounds  of  penis,  219 


H 


HAGNER  hemostatic  bag,  625 
Hard  chancre,  241 
Hematocele,  442,  476 
diagnosis  of,  476 

from  hydrocele,  467 
etiology  of,  476 
spontaneous,  476 
symptoms  of,  476 
traumatic,  476 
treatment  of,  477 
Hematoma  of  scrotum,  449 
Hematuria    in    carcinoma    of  prostate, 

673 

essential,  184 
in  syphilis  of  bladder,  182 
Hernia,   diagnosis   of,   from  hydrocele, 

467 

Hernial  sac,  hydrocele  of,  476 
Herpes  progenitalis,  231,  278 
diagnosis  of,  278 
etiology  of,  278 
inguinal  adenitis  and,  232 
symptoms  of,  278 
treatment  of,  232,  278 
Herpetic  urethritis,  334 
High-frequency  spark  operation  in  ob- 
struction of  prostate,  609 
Historical  sketch  of  genito-urinary  sur- 
gery in  America,  17 
Hunterian  chancre,  241 
Hydatid  of  Morgagni,  417 
Hydrocele,  461 
acute,  462 

course  of,  462 
diagnosis  of,  463 
symptoms  of,  463 
treatment  of,  463 
anatomy  of,  461 
chronic,  463 

complications  of,  467,  472,  473 
diagnosis  of,  466 

from  chylocele,  467 
from  hematocele,  467 
from  hernia,  467 
from  solid  tumor,  467 
from  spermatocele,  467 
light  test  in,  466 


732 


INDEX 


Hydrocele,  chronic,  diagnosis  of,  punc- 
ture in,  466 
epididymis  and,  465 
etiology  of,  463 
fluid  in,  464 

amount  of,  464 
examination  of,  465 
properties  of,  464 
pathology  of,  464 
prognosis  of,  467 
rupture  and,  467 
sac  in,  465 
suppuration  in,  467 
symptoms  of,  465 
testis  and,  465 
trauma  and,  463 
treatment  of,  468 

Andrew's  "bottle"  opera- 
tion in,  471 
aspiration  in,  470 
autoserotherapy  in,  468 
eversion  in,  471 
excision  in,  472 
open  operations  in,  471 
operative,  474 
tapping  in,  469 
vaccine  therapy  in,  468 
Winkelmann's  operation  in 

the,  472 
congenital,  475 

diagnosis  of,  475 
prognosis  of,  475 
treatment  of,  475 
of  cord,  475 

diagnosis  of,  475 
diffuse,  475 
encysted,  476 

treatment  of,  476 
symptoms  of,  475 
treatment  of,  476 
definition  of,  461 

due   to   abnormalities   of   develop- 
ment, 474 
of  a  hernial  sac,  476 

treatment  of,  476 
idiopathic,  463 
infantile,  475 

treatment  of,  475 
varieties  of,  461 
Hypertrophy  of  prostate,  cancer  and,  662 

of  testicle,  430 
Hypospadias,  202 
etiology  of,  204 
in  female,  350 

symptoms  of,  350 
treatment  of,  351 
glandular,  operation  for,  204 
Beck's,  204 
Duplay's,  204,  206 
penoscrotal,  operation  for,  207 
Beck's,  208 
Duplay's,  207 
perineal,  operations  for,  209 

Nove'-Josserand's,  209 
Rochet's,  211 
treatment  of,  204 


IDIOPATHIC  hydrocele,  463 
orchitis,  486 
varicocele,  479 
Incised  wounds  of  penis,  219 
Indigo-carmine   in   functional   tests   of 

kidneys,  128 

Indirect  catheterizing  cystoscopes,  66 
cystoscopes,  65 

in  ureteral  catheterization,  79 
optical  system,  60 
Infantile  hydrocele,  475 
Infiltration  of  Oberlander,  301 
Inflammation  of  penis,  230 
of  scrotum,  452 
of  urethra  in  female,  368 
of  verumontanum,  diagnosis  of,  from 
chronic    gonorrheal   prostatititis, 
312 

Ingestive  urethritis,  334 
Inguinal  adenitis,  283 

acute  anterior  gonorrheal  ure- 
thritis and,  305 
etiology  of,  284 
in  herpes  progenitalis,  231 
pain  in,  284 
symptoms  of,  284 
treatment  of,  284 
bubo,  283 
Intervesicular  space,  cancer  of  prostate 

and,  678 
Intestine    shadows,     roentgenology    of 

urinary  tract  and,  150 
Intravaginal  spermatocele,  477 
Intravesical    biopsy,    operative   cystos- 
copy  and,  91 


KELLY'S  cystoscope,  349 
endoscope,  68 

in  ureteral  catheterization,  84 
urethroscope,  349 

Kelly-Pawlik  endoscope  in  ureteral  cath- 
eterization, 85 
Keyes's  deep  urethral  syringe,  319 

Edward  L.,  historical  sketch  of,  27 
Kidney  drainage  of,  Watson's  apparatus 

for,  45,  46 
Kidneys,  functional  tests  of,  126 

indigo-carmine  in,  128 
methylene  blue  in,  128 
phenolsulphonephthalein 

in,  129 

technic  of,  130 
phloridzin  in,  128 
variability  of,  126 
gonococcal  infection  of,  334 
gumma  of,  190 

prognosis  of,  191 
symptoms  of,  191 
urine  in,  191 

Wassermann  reaction  in,  191 
infection  of,  gonorrheal  stricture  of 
urethra  and,  392 


INDEX 


733 


Kidneys,  pelvis  of,  capacity  of,  125 

diseases  of,  symptoms  of,  143 
obstruction  of,  diagnosis  of,  140 
syphilis  of,  184 

Kollman  posterior  urethral  dilator,  318 


LACERATED  wounds  of  penis,  219 

Levaditi's  staining  methods  in  diagnosis 
of  chancre,  251,  252 

Lewis's  universal  cystoscope,  63 

Lipoma  of  penis,  237 

Litholapaxy,  historical  sketch  of,  39 

Lithotrite,  Bigelow's,  40,  41 

Littre,  glands  of,  anatomy  of,  289 

Lupus  of  scrotum,  451 

Luy's  endoscope,  69 

in  ureteral  catheterization,  85 

Lymphadenitis,  chancroid  and,  283 

Lymphangitis,  acute  anterior  gonorrheal 

urethritis  and,  305 
chancroid  and,  283 
in  inflammation  of  penis,  231 

Lymphatics  of  penis,  anatomy  of,  198 


M 


MCCARTHY'S  close  vision  cysto-urethro- 

scope,  348 

Magnification  in  direct  optical  system,  59 
Malformations  of  penis,  congenital,  198 
of  testicle,  428 
of  urethra  in  female,  349 
Malposition  of  urethra  in  female,  350 
Meatotomy  in   gonorrheal  stricture  of 

urethra,  403 
ureteral,  operative  cystoscopy  and, 

91 

Meatus,  chancre  of,  161 
Membranous  urethra,  anatomy  of,  288 

cancer  of  prostate  and,  679 
Mercier  bicoude  catheter,  582 

coude  catheter,  582 
Methylene  blue  in  functional  tests  of 

kidneys,  128 

Morgagni,  hydatid  of,  417 
Mumps,  orchitis  and,  486 
Muscles  of  penis,  anatomy  of,  197 


N 

NEOPLASMS  of  scrotum,  459 

of  urethra  in  female,  357,  362 
Nephrectomy,  historical  sketch  of,  36 
Nephritis,  syphilitic,  acute  parenchyma- 

tous,  185 
anemia  in,  188 
diagnosis  of,  188 
dropsy  in,  188 
etiology  of,  185 
pathology  of,  187 
prognosis  of,  189 


Nephritis,  syphilitic,  acute  parenchyma- 
tous,  salvarsan  in, 
190 

symptoms  of,  188 
synonyms  of,  185 
treatment  of,  189 
urinary  findings  in, 

187,  188 
urine  in,  188 
Wassermann   reaction 

in,  188 
precox,  185 

Nephrolithotomy,  historical  sketch  of,  36 
Nephropexy,  historical  sketch  of,  37 
Nephroptosis,  pyelography  and,  155 
Nernst  lamp  in  diagnosis  of  chancre,  248 
Nerves  of  penis,  anatomy  of,  198 
Nitze  cystoscopes,  60,  62 

(direct)  optical  system,  amplication 

of  fields  in,  58 
Nitze-Albarran  catheterizing  cystoscope, 

66 
Noguchi  butyric  acid  test  in  diagnosis  of 

chancre,  255 
Non-gonococcic  urethritis  in  female,  368 

treatment  of,  369 

Non-gonorrheal  prostatitis,  diagnosis  of, 
from  chronic  gonorrheal  prostati- 
tis, 312 
urethritis,  334 

treatment  of,  334 
Non-venereal  genital  ulcers,  277 
Nove-Josserand's  operation  for  perineal 
hypospadias,  209 


OBERLANDER,  infiltration  of,  301 

Olivary  bougie,  317 

Operative  cystoscopy,  85 

Optical  system,  direct,  amplication  of 

fields  in,  58 
magnification  in,  59 
properties  of,  58 
indirect,  60 
prismatic,  60 
Orchitis,  idiopathic,  486 
mumps  and,  482 
smallpox  and,  486 
tonsillitis  and,  486 
typhoid  fever  and,  485 
Organ  of  Giraldes,  417 
Osteophytes,   roentgenology  of  urinary 

tract  and,  150 
Otis's  urethrotome  and  steel  sound,  52 
Otis-Brown-Nitze  prismatic  cystoscope, 

65 

Oudin  spark  in  treatment  of  caruncle  of 
female  urethra,  359 


PAIN  in  carcinoma  of  prostate,  672 
in  chancre,  245 


734 


INDEX 


Pain  in  chancroid,  281 

in  chronic  anterior  gonorrheal  ure- 

thritis,  308 

in  endo-urethral  chancre,  162 
in  genital  tuberculosis,  520 
in  gonorrheal  stricture  of  urethra. 

392 

in  inguinal  adenitis,  284 
in  syphilis  of  bladder,  182 
in  torsion  of  testicle,  444 
Painful  erections  in  acute  anterior  gonor- 
rheal urethritis,  303 
Papilloma  of  penis,  237 

of  urethra  in  female,  360 
Paradidymis,  417 
Paraphimosis,  225 

chancroid  and,  283 
treatment  of,  226 
Parenchymatous   prostatitis,   pathology 

of,  300 

syphilitic  nephritis,  acute,  185 
Pediculi  pubis  of  scrotum,  451 
Penile  urethra,  anatomy  of,  288 
Penis,  absence  of,  201 
actinomycosis  of,  236 
adherent,  202 
anatomy  of,  193 
arteries  of,  anatomy  of,  197 
burns  of,  229 
carcinoma  of,  237 
diagnosis  of,  239 
phimosis  and,  224,  237 
symptoms  of,  239 
treatment  of,  239 
cartilaginous  and  bony  formation  of, 

234 
chancre  of,  241 

chancrous  erosions,  245 

ulceration,  245 
classification  of,  244 
definition  of,  241 
diagnosis  of,  247 

dark-ground  illuminator  in, 

247 

Nernst  lamp,  248 
Reichert     instru- 
ment, 248 
differential,  255 
Noguchi  butyric  acid  test 

in,  255 

obtaining  material  for,  249 
preparation    of    materials 

for,  249 
Ross-Jones  modification  of 

Nonne  test  in,  255 
spinal  fluid  examination  in, 

254,  255 

staining  methods  in,  250 
Giemsa's,  250,251 
Levaditi's,  251 
Wassermann   reaction   in, 

253,  254 
etiology  of,  241 
histology  of,  243 
incubation  in,  244 
indurated  papule,  245 


Penis,    chancre   of,    indurated    papule, 

Hunterian,  245 
parchment,  245 

pain  in,  245 

pathology  of,  243 

prognosis  of,  256 

prophylaxis  in,  256 

Spirochseta  pallida  in,  241 

synonyms  of,  241 

treatment  of,  256 
excision  in,  256 
general,  256 
local,  256 
salvarsan  in,  256 
chondroma  of,  237 
cleft,  202 
concealed,  201 

treatment  of,  201 
condyloma  of,  237 
congenital  malformations  of,  198 
contusions  of,  218 

treatment  of,  218 
cysts  of,  dermoid,  237 

epithelial,  236 
dartos  of,  anatomy  of,  196 
diseases  of,  223 
dislocation  of,  220 

treatment  of,  221 
double,  199 

treatment  of,  201 
edema  of,  230 
elephantiasis  of,  236 
epispadias,  213 

etiology  of,  214 

treatment  of,  214 
erysipelas  of,  232 
fascia  of,  anatomy  of,  196 
fibroma  of,  237 
freezing  of,  229 
frenum  of,  disease  of,  223 
treatment  of,  223 
gangrene  of,  234 

treatment  of,  234 
gumma  of,  235,  259 
herpes  of,  231 
hypospadias  of,  202 

etiology  of,  204 

treatment  of,  204 
inflammation  of,  230 

balanoposthitis  in,  231 

etiology  of,  231 

lymphangitis  in,  231 

symptoms  of,  231 

treatment  of,  231 
injuries  of,  218 

subcutaneous,  226 
diagnosis  of,  227 
prognosis  of,  227 
symptoms  of,  227 
treatment  of,  227 
lipoma  of,  237 

lymphatics  of,  anatomy  of,  198 
muscles  of,  anatomy  of,  197 
nerves  of,  anatomy  of,  198 
papilloma  of,  237 
paraphimosis  of,  225 


INDEX 


735 


Penis,   paraphimosis  of,  treatment  of, 

226 

phimosis,  223.     See  Phimosis. 
phlegmon  of,  232 

symptoms  of,  232 
treatment  of,  232 
rupture  of,  220 

treatment  of,  220 
sarcoma  of,  239 

diagnosis  of,  239 

prognosis  of,  239 

skin  of,  affections  of,  232 

anatomy  of,  196 
strangulation  of,  221 

by  foreign  bodies,  229 
syphilis  of,  241.    See  Genital  Ulcers, 
torsion  of,  202 
tuberculosis  of,  234 

circumcision  and,  235 
pathology  of,  516 
treatment  of,  235 
tumors  of,  237 
ulcerated  papule  in,  259 
veins  of,  anatomy  of,  197 
wounds  of,  218,  219 
gunshot,  219 
incised,  219 
lacerated,  219 
open,  228 

treatment  of,  228 
punctured,  219 
treatment  of,  219 
Penoscrotal  hypospadias,  operations  for, 

207 
Perineal  drainage  in  cancer  of  prostate, 

713  . 

hypospadias,  operations  for,  209 
prostatectomy    in   enlargement    of 

prostate,  639 
after-treatment,  645 
enucleation  of  glands 

in,  643 

exposure  of  recto-ure- 
thral  muscle  in,  640 
incision  in,  640 
results  of,  646 
technic  of,  639 
through  median  incis- 
ion, 647 
wound  dressing  in,  644 
Peri-urethral     abscess,     acute     anterior 
gonorrheal     urethritis     and, 
304 
stricture  of  female  urethra  and, 

364 
Peri-urethritis,  acute  anterior  gonorrheal 

urethritis  and,  304 
gonorrheal  stricture  of  urethra  and, 

392 

Phagedena,  chancroid  and,  283 
syphilis  of  urethra  and,  167 
Phenolsulphonephthalein    in    functional 

tests  of  kidneys,  129 
Phimosis  in  adults,  224 
atrophic,  224 
balanoposthitis  in,  224 


Phimosis,  carcinoma  and,  227,  237 
chancroid  and,  282 
in  children,  224 
congenital,  223 

treatment,  225 
preputial  stones  and,  225 
Phleboliths.    roentgenology   of    urinary 

tract  ana,  150 
Phlegmons  of  penis,  232 
Phloridzin  in  functional  tests  of  kidneys, 

128 
Phosphatic   encrustations,    removal   of, 

operative  cystoscopy  and,  90 
Pigmented  moles,  roentgenology  of  urin- 
ary tract  and,  150 
Pilcher  hemostatic  bag,  626 

modification  of  de  Pezzer  catheter, 

615 

Pityriasis  versicolor  of  scrotum,  451 
PoUakiuria  in  syphilis  of  bladder,  182 
Polyorchism,  429 
Polypi  of  urethra  in  female,  360 
Postgonorrheal  urethritis,  334 
Posthitis,  230 

Preputial  stones,  phimosis  and,  225 
Priapism  in  diffuse  cavernositis,  233 
Primary  sclerosis,  241 
Prismatic  cystoscopes,  65 
Buerger's,  65 
Otis-Brown-Nitze,  65 
optical  system,  60 
Prolapse  of  urethra  in  female,  354 

treatment  of,  355 

Prostate,  anatomy  of,  541,  543,  554 
bloodvessels  of,  546 
calculus  disease  of,  723 
etiology  of,  723 
symptoms  of,  723 
treatment  of,  724 
cancer  of,  657 

bladder  and,  680 

Bottini  electrocautery  operation 

in,  712 

castration  in,  713 
catheter  life  in,  672 
catheterization  in,  713 
course  of,  671 
diagnosis  of,  669 

from  obstruction,  589 
duration  of,  674 
etiology  of,  658 
frequency  of,  657 
hematuria  in,  673 
histology  of,  660 
hypertrophy  and,  662 
intervesicular  space  and,  678 
loss  of  weight  in,  673 
membranous  urethra  and,  679 
pain  in,  672 
pathology  of,  659 
perineal  drainage  in,  713 
physical  signs  in,  674 
prostatectomy  in,  partial,  697 

suprapubic,  711 
radical  operation  for,  682 
radium  in  treatment  of,  715 


736 


INDEX 


Prostate,  cancer  of,  rectal  examination 

in,  675 

rectum  and,  679 
seminal  vesicles  and,  678 
stricture   of   prostatic   urethra 

and,  681 

subtotal  radical  incision  in,  698 
suburethral  thickening  and,  681 
suprapubic  drainage  in,  713 
symptoms  of,  665 
treatment  of,  681 
diseases  of,  symptoms  of,  142 
embryology  of,  541 
enlargement  of,  575 
bladder  in,  578 
etiology  of,  576 
kidneys  in,  578 
occurrence  of,  575 
ureters  in,  578 
urethra  in,  576 
gland,  anatomy  of,  289 
histology  of,  546 
hypertrophy  of,  cancer  and,  CG2 
lateral  aponeurosis  of,  544 
lymphatics  of,  546 
muscular  apparatus  of,  550 
nerve  supply  of,  551 
nerves  of,  546 
obstruction  of,  553,  617 
cystoscopy  in,  584 
dangers  of,  587 
technic  of,  584 
value  of,  586 
diagnosis  of,  581 

from  carcinoma,  589 
from    chronic    prostatitis, 

588 
from  retention  of  urine  due 

to  spinal  disease,  589 
from  tuberculosis,  588 
from  vesical  calculus,  590 

tumors,  589 
history  in,  581 
drainage  operation  in,  615 
enucleation  of  prostate  in,  620 
examination  in,  582 
high-frequency  spark  operation 

in,  609 
prostatectomy  in,  600 

epididymitis  and,  603 
fistulse  and,  604 
hemorrhage  in,  630 

control  of,  630-632 
impotence  and,  603 
incontinence  of  urine  and, 

603 

orchitis  and,  603 
perineal,  639 

after-treatment  in,  645 
enucleation    of    gland 

in,  643 

exposure  of  recto-ure- 
thral  muscle  in,  640 
incision  in,  640 
results  of,  646 
technic  of,  639 


Prostate,  obstruction  of,  prostatectomy 

in,  perineal,  through 

median  incision,  647 

wound  dressing  in,  644 

transvesical,  610 

by  open  method,  636 
urethral      stricture      and, 

605 

rectal  examination  in,  584 
suprapubic  cystostomy  in,  611 

technic  of,  613 
drainage  of  bladder  in,  633 
symptoms  of,  579 
treatment  of,  590 

of  acute  retention  of  urine, 

591 
of    cystitis    with    urinary 

stasis,  591 
hygienic,  590 
intermittent  catheterism 

in,  593 

intra-urethral,  592 
palliative,  593 
preliminary   to   prostatec- 
tomy, 600 

prostatectomy  in,  600 
surgical  indications  in,  595 
x-ray  examination  in,  587 
Young  punch  operation  in,  608 
pathology  of,  554 

gross,  555 
physiology  of,  549 
sarcoma  of,  720 

symptoms  of,  721 
treatment  of,  721 
secretion  of,  549 

surgery  of,  historical  sketch  of,  47 
syphilis  of,  168 
tuberculosis  of,  diagnosis  of,  from 

obstruction,  588 
pathology  of,  514 
symptoms  of,  521 

Prostatectomy  in  cancer  of  prostate,  par- 
tial, 697,  698 
suprapubic,  711 
in  enlargement  of  prostate,  600 
epididymitis  and,  603 
fistulse  and,  604 
hemorrhage  in,  630 

control  of,  630-632 
impotence  and,  603 
incontinence  of  urine  and, 

603 

orchitis  and,  603 
perineal,  639 

after-treatment  in,  645 
enucleation    of    gland 

in,  643 

exposure  of  recto-ure- 
thral  muscle  in,  640 
incision  in,  640 
results  of,  646 
t'echnic  of,  639 
through  median  incis- 
ion, 647 
wound  drainage  in,644 


INDEX 


737 


Prostatectomy  in  enlargement  of  pros- 
tate, stricture  of  urethra 
and,  605 
transvesical,  610 

by  open  method,  636 
Prostatic  abscess,  acute  posterior  gonor- 

rheal  urethritis  and,  306 
gonorrheal  stricture  of  urethra 

and,  392 

calculi,  pyelography  and,  159 
tractors,  642 
urethra,  anatomy  of,  288 

stricture  of,  cancer  of  prostate 

and,  681 

Prostatitis,  catarrhal,  pathology  of,  300 
chronic,  diagnosis  of,  from  obstruc- 
tion, 588 
pathology  of,  301 
follicular,  pathology  of,  300 
gonorrheal,  complement-fixation  test 

in,  311 

course  of,  311 
diagnosis  of,  311 
stricture  of  urethra  and,  392 
non-gonorrheal,  diagnosis  of,  from 

gonorrheal  prostatitis,  312 
parenchymatous,  pathology  of,  300 
Pruritus  of  scrotum,  451 
Punctured  wounds  of  penis,  219 
Pyelography,  155 
dangers  of,  124 
dark-room  technic  of,  160 
diverticula  of  bladder  and,  160 
exposure  for,  160 
nephroptosis  and,  155 
prostatic  calculi  and,  159 
stone  in  bladder  and,  160 
ureteral  calculi  and,  159 
uric  acid  stones  and,  155 
Pyemia  in  diffuse  cavernositis,  233 


RADIOGRAMS,  interpretation  of,  125 
Radiography  in  genito-urinary  diagnosis, 

123 
preparation  of  patient  for, 

126 

technic  and  mode  of,  126 
value  of,  123 
stereoscopic,  126 

Radium  in  treatment  of  cancer  of  pros- 
tate, 715 
Rectal   examination   in   obstruction   of 

prostate,  584 

Rectum,  cancer  of  prostate  and,  679 
Reichert    instrument    in    diagnosis    of 

chancre,  248 
Resection    of    bladder,    transperitoneal 

partial,  historical  sketch  of,  43 
of  fistula  in  gonorrheal  stricture  of 

urethra,  412 
of  urethra  in  gonorrheal  stricture, 

411 
Cabot's,  411 

M  u     i — 47 


Rochet's  operation  for  perineal  hypo- 

spadias,  211 
Roentgenology   of   urinary   tract,    147. 

See  also  Radiography, 
concretions    in    appendix 

and,  150 

gall-stones  and,  151 
intestine  shadows  and,  150 
osteophytes  and,  150 
phleboliths  and,  150 
pigmented  moles  and,  150 
preparation  of  patient,  147 
sources  of  error  in,  147 
technic  of,  152 
Ross-Jones  modification  of  Nonne  test  in 

diagnosis  of  chancre,  255 
Rupture  of  penis,  220 

treatment  of,  220 


S 


SALVARSAN  in  treatment  of  acute  paren- 
chymatous syphilitic  nephri- 
tis, 190 

of  chancre,  256 
Sarcoma  of  penis,  239 

of  prostate,  720 
Scabies,  diagnosis  of,  from  chancre,  255 

of  scrotum,  451 

Scrotal  hypospadias,  operations  for,  208 
Scrotum,  abnormalities  of,  449 
abscess  of,  452 
adenocarcinoma  of,  460 
anatomy  of,  447 

areolar  tissue  of,  anatomy  of,  448 
bloodvessels  of,  448 
calculi  of,  454 
carcinoma  of,  460 
cellulitis  of,  452 
chafing  of,  450 
cutaneous  diseases  of,  450 
dartos  of,  anatomy  of,  447 
eczema  of,  450 

marginatum  of,  451 
edema  of,  452 
elephantiasis  of,  filarial,  454 

associated    conditions    in, 

456 

diagnosis  of,  456 
edema  in,  456 
etiology  of,  454 
pathology  of,  455 
prophylaxis  in,  457 
symptoms  of,  456 
treatment  of,  457 
non-filarial,  459 
emphysema  of,  453 
erysipelas  of,  453 
erythema  intertrigo  of,  450 
gangrene  of,  453 
granuloma  of  pudenda,  453 
hematoma  of,  449 
inflammation  of,  452 
injuries  of,  449 
loss  of  substance  of,  449 


738 


INDEX 


Scrotum,  lupus  of,  451 
lymphatics  of,  448 
neoplasms  of,  459 
nerves  of,  449 
pediculi  pubis  of,  451 
pityriasis  versicolor  of,  451 
pruritus  of,  451 
scabies  of,  451 
sebaceous  cysts  of,  452 
skin  of,  447 
steatoma  of,  452 
suture  of,  450 
syphilis  of,  451 
varicose  veins  of,  452 
Sebaceous  cysts  of  scrotum,  452 
Seminal  vesicles,  anatomy  of,  291,  546 
bloodvessels  of,  549 
cancer  of  prostate  and,  678 
definition  of,  546 
diseases  of,  symptoms  of,  142 
embryology  of,  546 
histology  of,  549 
physiology  of,  549 
secretion  of,  549 
tuberculosis  of,   pathology  of, 

515 

symptoms  of,  521 
vesiculitis,    acute   posterior    gonor- 

rheal  urethritis  and,  306 
gonorrheal  stricture  of  urethra 

and,  392 

pathology  of,  301 
symptoms  of,  313 
.  treatment  of,  328 
operative,  328 
vasectomy  in,  329 
vasotomy  in,  329 

Sex  function  in  chronic  posterior  gonor- 
rheal urethritis,  310 
in  genital  tuberculosis,  522 
Simple  ulcer,  278 
Skin  of  penis,  affections  of,  232 

anatomy  of,  196 
of  scrotum,  anatomy  of,  447 
Smallpox,  orchitis  and,  486 
Soft  chancre,  278 

rubber  catheter,  582 
Sounds,  use  of,  in  gonorrheal  stricture  of 

urethra,  395,  399 
Spermatocele,  477 
diagnosis  of,  478 

from  hydrocele,  437 
etiology  of,  477 
extravaginal,  477 
fluid  in,  478 
intravaginal,  477 
pathology  of,  478 
symptoms  of,  478 
treatment  of,  478 
Spinal  cord  affections  simulating  syphilis 

of  bladder,  184 
fluid   examination   in   diagnosis   of 

chancre,  254,  255 

Spirochaeta  pallida,  characteristic  fea- 
tures of,  as  observed  with  dark-field 
condenser,  241 


Spirochaeta  pallida,  ends  of,  242 
motility  of,  242 
shape  of,  242 
size  of,  242 
Spongeitis,    acute    anterior    gonorrheal 

urethritis  and,  305 
Spontaneous  hematocele,  476 
Steatoma  of  scrotum,  452 
Stereoscopic  radiography,  126 
Stone  in  bladder,  pyelography  and,  160 
preputial,  phimosis  and,  225 
stricture  of  urethra  and,  416 
in  ureter,  symptoms  of,  143 
uric  acid,  pyelography  and,  155 
Strangulation  of  penis,  221 

by  foreign  bodies,  229 
Stricture,  treatment  of,  by  electrolysis, 

opposition  to,  53 
Of  urethra  in  female,  364,  416 
diagnosis  of,  365 
peri-urethral  abscess  and, 

364 

symptoms  of,  364 
treatment  of,  365 
urethrotomy  in,  external, 

366 

internal,  365 
in  male,  384 

bilharzia  and,  416 
carcinoma  and,  416 
chancroid  and,  416 
classification  of,  384 
congenital,  414 

clinical  types  of,  415 
diagnosis  of,  415 
etiology  of,  415 
pathology  of,  415 
treatment  of,  415 
foreign  bodies  and,  416 
gonorrheal,  386 

chronic    urethral    dis- 
charge in,  390 
complications  of,  392 
course  of,  393 
cure  of,  394 
diagnosis  of,  394 
epididymitis  and,  392 
etiology  of,  386 
form  of,  388 
hemorrhage  in,  391 
location  of,  387 
onset  of,  389 
pain  in,  392 
pathology  of,  386 
peri-urethritis  and,392 
prognosis  of,  393 
prostatic  abscess  and, 

392 

prostatitis  and,  392 
renal  infection  and, 392 
symptoms  of,  389 

sexual,  392 
treatment  of,  397 

anesthesia  in,  398 
antisepsis  in,  398 
bougies  in,  398 


INDEX 


739 


Stricture  of  urethra  in  male,  gonorrheal, 
treatment  of, 
dilatation  in, 
398 

meatotomy  in,403 
operative,  402 
palliative,  397 
preventive,  397 
resection    of    fis- 
tula, 412 
of  urethra,411 
sounds  in,  399 
urethrotomy     in, 

404,  405 

urination  in,  390 
vesiculitis  and,  392 
statistics  of,  385 
stone  and,  416 
syphilis  and,  167,  416 
traumatic,  412 
course  of,  413 
pathology  of,  413 
symptoms  of,  413 
treatment  of,  414 
tuberculosis  and,  415 
Suburethral   abscess,    acute   gonorrheal 

urethritis  in  female  and,  379 
thickening,  cancer  of  prostate  and, 

681 
Suprapubic  cystostomy  in  enlargement 

of  prostate,  611 
drainage  of  bladder  in  obstruction  of 

prostate,  633 
in  cancer  of  prostate,  713 
prostatectomy  in  cancer  of  prostate, 

711 

Synorchism,  430 

Syphilides,  urethral  mucous,  164 
Syphilis  of  bladder,  169 

pathology  of,  181 
secondary,  173 
age  in,  181 
cystoscopy  in,  181 
symptoms  of,  181 
tertiary,  175 
age  in,  182 
cystoscopy  in,  182 
diagnosis  of,  182 
hematuria  in,  182 
pains  in,  182 
pollakinuria  in,  182 
spinal  cord  affections  simu- 
lating, 184 
symptoms  of,  182 
treatment  of,  183 
of  genito-urinary  organs,  161 
initial  lesions  of,  241 
of  kidney,  184 

of  penis,' 241.    See  Genital  Ulcers, 
of  prostate,  168 
of  scrotum,  451 

stricture  of  urethra  and,  167,  416 
of  ureter,  184 
of  urethra,  161 
primary,  161 

chancre  of  meatus,  161 


Syphilis  of  urethra,  primary,  complica- 
tions of,  163 
diagnosis  of,  163 
endo-urethral  chancre,  162. 
frequency  of,  161 
location  of,  161 
secondary,  164 
tertiary,  164 

complications  of,  167 
modes  of  invasion.  165 
phagedena  and,  167 
prognosis  of,  168 
stricture  and,  167 
symptoms  of,  165 
time  of  appearance,  165 
treatment  of,  168 

Syphilitic  hypertrophy   of    vulva    with 
ulceration,  260.     See  Esthiomene. 
nephritis,  acute  parenchyma tous,  185 
anemia  in,  188 
diagnosis  of,  188 
dropsy  in,  188 
etiology  of,  185 
pathology  of,  187 
prognosis  of,  189 
salvarsan  and,  190 
symptoms  of,  188 
synonyms  of,  185 
treatment  of,  189 
urinary  findings  and, 

187,  188 
urine  in,  188 
Wassermann  reaction 

in,  188 

urethritis,  334 
Syphiloma  of  urethra,  cylindroid,  165 


TAPPING  in  treatment  of  hydrocele,  469 
Testicle,  anatomy  of,  420 
blood  supply  of,  425 
descent  of,  417 
imperfect,  430 

diagnosis  of,  436 
effect  on  testicle,  433 
incidence  of,  431 
torsion  and,  435,  443 
treatment  of,  436 

Bevan's,  438,  441 
operative,  437 
dislocation  of,  442 
ectopia  of,  432 
embryology  of,  417 
histology  of,  422 
infections  of,  485 
diagnosis  of,  494 
etiology  of,  485 
pathogenesis  of,  487 
pathology  of,  487,  490 
prognosis  of,  495 
symptoms  of,  494 
syphilis  and,  486 
treatment  of,  496 
injuries  of,  442 


740 


INDEX 


Testicle,  luxation  of,  432,  442 
lymphatics  of,  426 
malformations  of,  428 
anorchism,  430 
atrophy,  430 
hypertrophy,  430 
polyorchlsm,  429 
synorchism,  430 
nerves  of,  426 
physiology  of,  426 
torsion  of,  443 
age  and,  443 
cause  of,  443 
diagnosis  of,  444 
edema  of  skin  in,  444 
incidence  of,  443 
pain  in,  444 
pathology  of,  443 
symptoms  of,  444 
treatment  of,  445 
undescended  testicle  and,  435, 

443 
tuberculosis  of,  pathology  of,  511 

symptoms  of,  522 
tumors  of,  534 

clinical  picture  of,  536 
diagnosis  of,  536 
etiology  of,  534 
frequency  of,  534 
pathology  of,  534 
prognosis  of,  537 
trauma  and,  534 
treatment  of,  538 
undescended,  430 
diagnosis  of,  436 
effect  of,  on  testicle,  433 
incidence  of,  431 
torsion  and,  435,  443 
treatment  of,  436 
operative,  437 

Bevan's,  438H141 
Testis,  anatomy  of,  422 
Thiersch's  operation  for  epispadias,  214 
Tonsillitis,  orchitis  and,  486 
Torsion  of  penis,  202 

of  testicle,  443 

Transperitoneal    total  cystectomy,  his- 
torical sketch  of,  43 

Transvesical  prostatectomy  in  enlarge- 
ment of  prostate,  610 
by  open  method,  636 
Traumatic  hematocele,  476 

stricture  of  urethra  in  male,  412 
urethritis,  334 

Tubercle  bacilli  in  urine,  absence  of,  in 

diagnosis  of  lesions  of  urinary  tract,  133 

Tuberculin  tests,  diagnosis  of  lesions  of 

urinary  tract  and,  134 
Tuberculosis  of  epididymis,  498 
diagnosis  of,  499 
pathology  of,  511 
prognosis  of,  499 
symptoms  of,  519 
treatment  of,  499 
genital,  498 

bladder  in,  521 


Tuberculosis,  genital,  etiology  of,  517 
fever  in,  521 
fistula  in,  520 
incidence  of,  500 
pain  in,  520 
pathogenesis  of,  503 
pathology  of,  509 
sex  function  in,  522 
symptoms  of,  519 
urine  in,  521 

genito-urinary,  incidence  of,  500 
of  penis,  234 

circumcision  and,  235 
pathology  of,  516 
treatment  of,  235 

of  prostate,  diagnosis  of,  from  ob- 
struction, 588 
pathology  of,  514 
symptoms  of,  521 
of  seminal  vesicjes,  pathoiogy  of,  515 

symptoms  of,  521 
stricture  of  urethra  and,  415 
of  testicle,  pathology  of,  511 

symptoms  of,  522 
of  urethra,  pathology  of,  516 
of  vas  deferens,  pathology  of,  515 

symptoms  of,  522 
Tumors  of  bladder,  diagnosis  of,  from 

obstruction  of  prostate,  589 
operations  for,  historical  sketch 

of,  43 

of  penis,  237 
of  testicle,  534 

Tunica  vaginalis,  anatomy  of,  421 
Typhoid  fever,  orchitis  and,  485 


ULCERS,  genital,  240.  See  Genital  Ulcers. 
Ulcus  durum,  241 

molle,  278 

Undescended  testicle,  430 
Universal  catheterizing  cystoscope,  68 
Ureter,  diseases  of,  symptoms  of,  142 
obstruction  of,  diagnosis  of,  140 
stone  in,  symptoms  of,  143 
syphilis  of,  184 
Ureteral  calculi,   descent  of,   operative 

cystoscopy  and,  90 
diagnosis  of,  operative  cystos- 
copy and,  88 
pyelogtaphy  and,  159 
catheterization,  79,  122 

cystoscope  in,  direct,  83 
Elsner-Braasch,  84 
indirect,  79 

endoscope  in,  Kelly's,  84 
Kelly-Pawlik,  85 
Luy's,  85 

lack  of  drainage  after,  123 
obstructions  in,  123 
wax-tip  bougies  jn,  122 
implantation,  historical  sketch  of,  44 
meatotomy,    operative    cystoscopy 
and,  91 


INDEX 


741 


Ureterocele,    operations    on,    operative 

cystoscopy  and,  91 

Urethra,  cyfindroid  syphiloma  of,  165 
in  enlargement  of  prostate,  576 
examination  of,  instrumental,  116 

anesthesia  in,  117 
female,  absence  of,  349 

anatomy  of,  336 

anesthesia  of,  343 

calculus  of,  356 

diagnosis  of,  356 
symptoms  of,  356 
treatment  of,  357 

carcinoma  of,  362 

caruncle  of,  358 

pathology  of,  358 
symptoms  of,  358 
treatment  of,  359 

catheter-trauma  of,  353 

catheterization  of,  353 

cysts  of,  360 

diseases  of,  symptoms  of,  144 

diverticulum  of,  366 
symptoms  of,  367 
treatment  of,  367 

double,  350 

examination  of,  341 

instruments  for,  344 

inflammations  of,  368 

injuries  of,  352 

inspection  of,  342 

malformations  of,  349 

malposition  of,  350 

neoplasms  of,  357 
benign,  357 
malignant,  358,  362 

palpation  of,  342 

papilloma  of,  360 

treatment  of,  362 

physiology  of,  339 

polyp  of,  360 

prolapse  of,  354 

treatment  of,  355 

stricture  of,  364 

diagnosis  of,  365 
peri-urethral  abscess  and, 

364 

symptoms  of,  364 
treatment  of,  365 
urethrotomy  in,  365,  366 

urethroscopy  of,  344 
male,  anatomy  of,  287 

anterior,  comparison  with  pos- 
terior, 292 

diseases  of,  symptoms  of,  141 

glands  of,  289 

interior  of,  289 

landmarks  of,  288 

membranous,  288 

cancer  of  prostate  and,  679 

penile,  288 

posterior,      comparison      with 
anterior,  292 

prostatic,  288 

cancer  of  prostate  and,  681 

size  of,  289 


Urethra,  male,  stricture  of,  384' 
bilharzia  and,  416 
carcinoma  and,  416 
chancroid  and,  416 
classification  of,  384 
congenital,  etiology  of,  415 
pathology  of,  415 
treatment  of,  415 
foreign  bodies  and,  416 
gonorrheal,  386 

chronic  urethral  discharge 

in,  390 

complications  of,  392 
congenital,  414 
course  of,  393 
cure  of,  393 
diagnosis  of,  394 
epididymitis  and,  392 
etiology  of,  386 
forms  of,  388 
hemorrhage  in,  391 
location  of,  387 
onset  of,  389 
pain  in,  392 
pathology  of,  386 
peri-urethritis  and,  392 
prostatic  abscess  and,  392 
renal  infection  and,  392 
sexual  symptoms  in,  392 
symptoms  of,  389 
traumatic,  412 
treatment  of,  397 

anesthesia  in,  398 
antisepsis  in,  398 
bougies  in,  398 
dilatation  in,  398 
meatotomy  in  403 
operative,  402 
palliative,  397 
preventive,  397 
resection  of  fistula,  412 

of  urethra,  411 
sounds  in,  399 
urethrotomy    in,   404, 

405,  409 
urination  in,  390 
vesiculitis  and,  392 
statistics  of,  385 
syphilis  and,  167,  416 
tuberculosis  and,  415 
surgery  of,  historical  sketch  of,  51 
syphilis  of,  161 
primary,  161 

chancre  of  meatus,  161 

symptoms  of,  162 
complications  of,  163 
diagnosis  of,  163 
endo-urethral  chancre,  162 
symptoms  of,  166 
frequency  of,  161 
location  of,  161 
secondary,  164 
tertiary,  164 

complications  of,  167 
modes  of  invasion,  165 
phagedena  and,  167 


742 


INDEX 


Urethra,  syphilis  of,  tertiary,  prognosis 

of,  168 

strictures  and,  167 
symptoms  of,  165 
time  of  appearance,  165 
treatment  of,  168 
tuberculosis  of,  pathology  of,  516 
Urethral  discharge  in  chronic  posterior 

gonorrheal  urethritis,  310 
in        gonorrheal     stricture    of 

urethra,   390 
glands,   abscess  of,   acute  anterior 

gonorrheal  urethritis  and,  304 
mucous  syphilides,  164 
syringe,  315 

Urethritis,  diathetic,  334 
eczematous,  334 
in  female,  acute  simple,  368 

treatment  of,  369 
gonorrheal,  370 
acute,  373 

complications  of,  378 
cystitis  and,  378 
etiology  of,  373 
examination  in,  374 
suburethral       abscess 

and,  379 
symptoms  of,  373 
treatment  of,  376 
urethroscope  in,  375 
chronic,  379 

diagnosis  of,  381 
pathology  of,  380 
symptoms  of,  380 
treatment  of,  382 
urethroscope  in,  381 
urine  in,  381 
examination  for,  371 
pyuria    without    urethral 

discharge  in,  371 
non-gonococcic,  368 

treatment  of,  369 

gonorrheal,  acute  anterior,  abscess  of 
urethral  glands  and, 
304 
balanoposthitis     and, 

305 
burning  on  urination 

in,  303 

cavernitis  and,  305 
complications  of,  304 
course  of,  304 
diagnosis  of,  304 
discharge  in,  303 
incubation  in,  302 
inguinal  adenitis  and, 

305 

invasion  in,  302 
lymphangitis  and,  305 
painful    erections    in, 

303 

pathology  of,  299 
peri-urethral     abscess 

and,  304 

peri-urethritis        and, 
304 


Urethritis,    gonorrheal,    acute   anterior, 
red      and     swollen 
meat  us  in,  303 
symptoms  of,  302 
spongeitis  and,  305 
urine  changes  in,  303 
variations  in  attack  of, 

303 

etiology  of,  298 
posterior,     acute     seminal 
vesiculitis  and,  307 
complications  of,  306 
course  of,  306 
cowperitis  and,  306 
frequency  of  urinaticn 

in,  305 

pathology  of,  299 
prostatic  abscess  and, 

306 

symptoms  of,  305 
urinary    changes     in, 

306 

case  treatment  of,  319 
chronic  anterior,  cause  of,  307 
complement-fixat  ion 

test  in,  309 
complications  of,  309 
diagnosis  of,  309 
instrumentationin,  308 
pain  in,  308 
palpation  in,  308 
symptoms  of,  307 
urethral  discharge  in, 

308 

urethroscopy  in,  308 
pathology  of,  301 
posterior,  complications  of, 

312 

disturbances  in  sexual 
function  in,  310 
of    urination    in, 

310 

etiology  of,  309 
exacerbations  in,  310 
instrumentation  in,31 1 
pain  in,  310 
palpation  in,  310 
pus  in  urine  in,  310 
symptoms  of,  309 
urethral  discharge  in, 

310 

urethroscopy  in,  311 
prophylaxis  against,  313 
treatment  of,  313 
anodynes  in,  315 
antigonococcus    serum    in, 

327 

balsamics  in,  314 
bowels  in,  314 
bulbous  bougie  in,  317 
dilatations  in,  317 
discharge  in,  314 
food  in,  314 

hygienic  cleanliness  in,  314 
internal  medication  in,  314 
prostatic  massage  in,  316 


INDEX 


743 


Urethritis,    gonorrheal,    treatment    of, 

rest  in,  314 

urethral  injections  in,  315 
instillations  in,  318 
irrigation  in,  316 
vaccines  in,  327 
herpetic  334 
ingestive,  334 
non-gonorrheal,  334 

treatment  of,  334 
postgonorrheal,  334 
syphilitic,  334 
traumatic,  334 
Urethrocele,  366 
Urethroscope  and  light  carrier,  Young's, 

347 

Kelly's,  349 

Urethroscopes,  selection  of,  105 
Urethroscopic  picture,  normal,  of  poste- 
rior urethra,  98 
pathological,  of  anterior  urethra 

94 
of  lacunse  of  Morgagni  and 

Littre's  glands,  94 
of  posterior  urethra,  95,101 
Urethroscopy,  92 

in  chronic  anterior  gonorrheal  ure- 
thritis, 308 
posterior  gonorrheal  urethritis, 

311 
in  diagnosis  of  gonorrheal  stricture 

of  urethra,  395 
in  female,  105 

urethra,  344 
in  gonorrheal  urethritis  in  female, 

375,  381 
operative,  104 

in  anterior  urethra,  104 
in  posterior  urethra,  104 
technic  of,  92 
in  treatment  of  stricture  of  urethra 

in  female,  365,  366 
Urethrotome,  Otis's,  52 
Urethrotomy,    external    with    guide,  in 
gonorrheal  stricture  of   ure- 
thra, 405 
without   guide,    in    gonorrheal 

stricture  of  urethra,  409 
internal,  in  gonorrheal  stricture  of 

urethra,  404 

Uric  acid  stones,  pyelography  and,  155 
Urinary  findings  in  acute  parenchyma- 
tous  syphilitic  nephritis,  187,  188 
obstruction  without  enlargement  of 

prostate,  579 
tract,  lesions  of,  diagnosis  of,  107 

absence  of  tubercle 
bacilli  in  urine  and, 
133 

cardiovascular  exami- 
nations and,  136 
change  in  urine  in,  114 
changes     in     urinary 

stream  in,  115 
chemical  examination  | 
in,  116 


Urinary  tract,  lesions  of,   diagnosis  of, 
cloudy     urine    and, 
132 
complement-fixation 

test  and,  135 
examination  of  urine 

in,  131 

functional  tests  in,  12  S 
guinea-pig  inoculation 

and,  134 

history  of  case  in,  112 
instrumentation  in,  116 
local  examination  in, 

115 
method  in  quest  for, 

110 

microscopic   examina- 
tion in,  116 
physical    examination 

in,  115 
plan  of  investigation. 

112 

previous  personal  his- 
tory in,  113 
relative  value  of  symp- 
toms  and   physical 
examination        for, 
110 
tuberculin   tests   and, 

134 
Wassermann  tests  and 

136 
middle,  diseases  of,  diagnosis  of, 

radiography  in,  124 
obstruction  of,  diagnosis  of,  137 
in  bladder,  140 
in  renal  pelvis,  140 
in  ureter,  140 
urethral,  137 
at  vesical  neck,  138 
roentgenology  of,  147.     See  also 

Radiography, 
upper,  diseases  of,  diagnosis  of, 

radiography  in,  124 

Urination   in    chronic    posterior    gonor- 
rhea! urethritis,  310 
in  gonorrheal  stricture  of  urethra, 

390 
Urine  in  acute  parenchymatous  syphilitic 

nephritis,   188 
changes  in,  in  gonorrheal  urethritis, 

303,  306,  381 
examination  of,  131 
in  genital  tuberculosis,  521 
in  gumma  of  penis,  191 
pus  in,  in  chronic  posterior  gonor- 
rheal urethritis,  310 
retention  of,  due  to  spinal  disease, 
diagnosis  of,  from  obstruction  of 
prostate,  589 

tubercle  bacilli  in,  absence  of,  in 
diagnosis  of  lesions  of  urinary 
tract,  133 

Urogenital  mesentery,  422 
Urologists,  associations  of,  organizations 
of,  18 


744 


INDEX 


Urology  in  America,  evolution  of,  34 
contributions  of  American  Surgeons 
to,  35 


VACCINE  therapy  in  treatment  of  hydro- 

cele,  468 
Vaccines  in  treatment  of  gonorrheal  epi- 

didymitis,  332 
urethritis,  327 

Van  Buren,  W.  H.,  historical  sketch  of,  18 
Varicocele,  479 

anatomy  of,  479 
idiopathic,  479 

complications  of,  482 
diagnosis  of,  480 
etiology  of,  479 
pathology  of,  480 
symptoms  of,  480 
treatment  of,  480 

operative,  480 
operations  on,  historical  sketch  of, 

53 

symptomatic,  479 
diagnosis  of,  479 
treatment  of,  479 
Varicose  veins  of  scrotum,  452 
Vas  deferens,  anatomy  of,  291 

tuberculosis  of,   pathology  of, 

515 

symptoms  of,  522 
Veins  of  penis,  anatomy  of,  197 
Venereal  ulcer,  simple,  278 

warts,  237 

Vesical  calculus,  operations  for,  historical 
sketch  of,  39 


Vesical  tumors,  operations  for,  historical 

sketch  of,  40 
Vision  systems,  correct,  61 


W 


WARTS,  venereal,  237 
Wassermann  reaction  in  acute  parenchy- 
matous    syphilitic   nephritis, 
188 

in  diagnosis  of  chancre,  252,  254 
of  lesions  of  urinary  tract, 

136 

in  gumma  of  penis,  191 
Watson,  Francis  S.,  historical  sketch  of, 

32 

Watson's  apparatus  for  drainage  of  kid- 
ney, 45,  46 
bladder  speculum,  56 
scissors  cautery,  55 
Winkelmann's  operation  for  hydrocele, 

472 

Wounds  of  penis,  218,  219 
gunshot,  219 
incised,  219 
lacerated,  219 
open,  228 
punctured,  219 
treatment  of,  219 


YOTTNG'S  prostatic  tractor,  142 

punch  operation  in  obstruction  of 

prostate,  608 
urethroscope  and  light  carrier,  347 


Date  Due 


APR 

1952 

Dtu   ; 

I:   , 

NOV   2  1 

1957 

Nov  1^60 

Aug  i3  o2 

W    30  ^ 

A  pp    .    / 

RXp9 

Ltbrary  Bureau  Cat.  no.  113'!' 


I  Cabot,  Hugh. 

Modern  urology. 


3  1970  00315  1112 


JREGIONAL.LIBRARYFACIUTY 


A  000  548  283  1 


WJ100 
Cll6m 
1918 
v.  1 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


